Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This post was originally published at Zócalo Public Square, a non-profit ideas exchange that blends live events and humanities journalism.

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443 Responses for “How Doctors Die”

  1. Tschwiet MD says:

    Ken,
    Your article moved me. It is a much more elegant explanation than I could have provided regarding my own beliefs about end-of-life and/or futile care. As a primary care physician who has witnesses the tragic loss of dignity in dying over and over again, we seem to be on the exact same wavelength on this issue. Thanks for sharing.

  2. Mary says:

    Great article. Everyone should read it. Interesting that the people who know the most choose the least care.

  3. DeterminedMD says:

    It will be interesting to read if anyone attacks this post. “What, doctors won’t practice what they preach!?” Or, is it really about doctors are afraid to be frank and direct with people? Or, is it this culture doesn’t think that death applies to people who live in an advanced society.

    Personally , the more advanced people seem to think they are getting, the more regressive and primitive they seem to think and act in the end.

    I like this post. But, reality is not want people want at this site, eh?

  4. DeterminedMD says:

    Like I really am concerned about what you think when I write a comment.

    Thanks for the validation of my last sentence in the prior comment, SIR!

    If you don’t like what someone says, how about this for an idea, ignore it!?

    But, you just have to reply, don’t you. Await your next last word, eh?

  5. steve says:

    The author does not cite a lot of data to support his assertion, but it certainly rings true for me. It also tends to extend out to their families. I think a lot of it is that we actually talk for and plan fro what we want at the end of life. Most people dont think about it until it happens.

    Steve

    • Kim says:

      I did a talk on end of life issues and spent quite a bit of time looking up the data on the use of DNR, whether they are followed, and results. Found out that over 50% of families, in one study, went against the patient’s wishes for Do Not Resuscitate. Doctors tend,for the most part, to follow them. While most medical people (doctors, nurses, care givers in general) tend to prefer DNR status for themselves, some, still prefer the do everything school of thought. Doctors, with dementia, in one study wanted more done, even when they know (or knew) that medical science does not have the tool they wish. However, doctors, in general, (except nephrologists) are not good about making sure their patient’s know about advance directives and the DNR status. This talk, according to studies, should begin when patient’s are young and healthy!

  6. Peter1 says:

    Doctors give patients treatment options, not death options. Patients always think they can beat the odds, that’s why Las Vegas makes money.

    • MG says:

      That’s oversimplifying it a bit but it gets to the point how the research I have seen conducted on how patients view this – ‘as literally as long as I have a chance I will do it.’

      Personally, I would not go thorough some kind of intensive medical intervention with dramatic side effects if it just increased my chances marginally of living another say 6 months with a horrendous quality of life. I would imagine I am outlier among the general public though.

  7. A great and poignant piece… Difficult decisions are usually involved. When I was a resident, I typically ran “soft” codes, for those who can understand this med lingo. Hated the hour-long flogs that more aggressive residents would force. They were truly beating dead horses.

    • dr. No says:

      Soft codes are illegal and unethical!!

      • No, they’re not at all. I completely and wholeheartedly disagree with you. It all depends on the situation.

      • DrJC says:

        Not at all. I too, like most of my similarly minded residents, would run those soft codes for families who were not ready so that they may see that we were making an effort, but what that patient was going through. They almost, universally, resulted in families making decisions to stop resuscitative efforts and allow patients to pass in peace.

        There is absolutely NOTHING wrong with that.

  8. Samuel Stenes, MD says:

    With the advent of indifference by our colleagues as they spend more time with the computer electronics ordering and less time with the patients, I will sooner die than go into the hospital to have my cancer governed by Medicare, point and click treatments, and cut and paste progress notes which no one has time to read except for the payors.

    • steve says:

      Certainly not what I see with our oncologists or oncology surgeons. I have talked with our guys and Medicare does not dictate care. It does not in my field. What cancer care does Medicare dictate where you live?

      Steve

      • dr. No says:

        Medicare dictated care is just plain absurd. Hospitals will do everything when you are hospitalized. If medicare does not cover, than good luck paying the bill yourself!

  9. mike says:

    What an interesting post. “Futile care” must be one of the hardest things to deal with as a doctor…

  10. Sean Scorvo says:

    This post rang true on a very personal level. During my early years in practice, I took a measure of pride in the fact that I never “lost” a patient in critical care situations…youthful hubris. In the years before leaving the ER for business, I felt guilt for the same outcomes…those “outcomes” being “saves” I wouldn’t have wished for myself, my friends, or my family. This post spoke to my feelings on the matter in a way I’ve never been able to voice.

  11. Janie Williams, RN says:

    The doctor for whom I work will die from aggravation from knowing her patients have died due to flawed EHRs and CPOEs and know one seems to care. How could these dangerous devices be used for medical care without any oversight? Terrible!!

    Janie

  12. Larry B says:

    I will make it short as compared to many of the others. I spend hours everyday reviewing articles and posting within our profession everyday. The boring part of being a research. This Dr. Murray, this is one of the most insightful and well thoughout articles I have ever read. Some may disagree, but it is rare that a healthcare professional actually describes what many feel.

  13. GTJon says:

    I feel as though the author tangentially hit on this point, but did not elaborate. And that is many times doctors and researchers (sometimes they are the same) often try to convince patients to fight as long as possible or recommend a course of treatment they know may not be best simply for data. There was a play (and later a movie I believe) that did a great job on this topic, called Wit. At what point does a patient stop becoming a person and start becoming an experiment. The output being data rather than quality of life.

  14. Trish P says:

    Thoughtprovoking – I feel should at least get people to thinking about end-of-life-decisions. However, too much emphasis on decision making in the ER. I don’t think it unreasonable for a family to “do everything” in the moment when a person is unexpectedly unconscious – their family member may be the one who survives. But when futility becomes apparent, I agree health care providers need to more strongly counsel toward comfort care. Example: my father-in-law fell down a flight of stairs and was unresponsive at the scene. CPR/defibrillation used and he was transported to the local trauma center. Over the next 24 hours as test results came in, it became apparent he had a C2 spinal cord injury as well as hypoxic injury from down time. Our family elected to institute comfort care measures, he was extubated and died within minutes surrounded by family.

  15. Fritze Rodic says:

    What a terrific article – very thoughtprovoking – would like to share my thoughts/experience regarding healthcare in Denmark (socialized medicare) where I was born and raised.

    • Kristen says:

      I would love to hear your perspective since you have lived in Denmark where socialized medicine is practiced.

      Thank you. Look forward to hearing back from you soon.

  16. Philip Schwarzman,MD says:

    As a society,we are in the Dark Ages when it comes to end of life care and it is bankrupting our healthcare system. As an an ER doc for 34 years being “forced”to resusitate patients at the insistence of family members or because there was no available advanced directive is very frustrating on many levels. In many situations,it is a cultural/religious issue and in those instances,the informed advice of a compassionate physician doesn’t trump orthodoxy.People are absolutely entitled to their beliefs and I (and my MD colleagues) will always honor their wishes. But should we as a society pay for futile care to satisfy someone’s religious belief ? I know it sounds cynical,but every ER doc knows that if Billy wants “everything ” done to save his 89 year old demented,bedridden,tubed dear Dad, but had to pay for it,he might find a new religion.

  17. John Ballard says:

    Dr. Schwarzaman, you just gave me an idea. It’s not politically or socially feasible but I’ll float it anyway—

    Medical professionals are not obliged to participate in an abortion if they claim a religious objection.
    Some religious faiths refuse to allow blood transfusions and (except for minors) that objection is honored without legal consequences.
    What would be the consequences of a physician (or any other medical professional) allowing life to come to a natural end, without heroic interventions, citing personal religious beliefs? I’m thinking of your example above.
    Passively allowing nature to take its course is surely not the same as assisted suicide or manslaughter. Or are doctors held to a different standard from other professionals?

    Just asking.

  18. Philip Gould says:

    This was a wonderful and courageous piece. I really appreciate this kind of honesty from a Doctor. When I was young, 50 years ago, I wanted to be a doctor, like Dr. Kildare or Ben Casey. So did my mother. In high school I was president of the Medical Club, and enter U.C. Berkeley as Pre-Med. Chemistry 1-A did me in, and I changed my major after one semester.
    All my life I was taught to respect doctors. But about seven years ago, while spending every day with my mother in the hospital, my eyes were opened. The system, the attitudes, the lack of awareness, the money, the pressures, etc., I believe, have made the health care system much less than it was intended to be.
    At the same time I learned about the value of Nutritional Supplements, diet, and exercise as a way to turn things around in my own case, and take control of my own health. I also learned of the risks in blindly following what doctors and hospitals tell us. I will listen, but I will question every little thing. I will read every label and decide for myself. My medical care is 100% my responsibility. Its my body. If I can learn I will. But I am very sensitive to anything a doctor or nurse tells me.
    I believe it is time for a major revolution in the way we train doctors and educate people about how to take care of themselves. The Doctor patient relationship should be more like a partnership, that a parent-child, or master-servant relationship. Patients have every right to question doctors. They should never be forced to stay in a hospital. When the risks of negligence and adverse drug side effects are worse than the symptoms…. beware. Patients must become more proactive, and doctors need to be models of good health. Doctors should not be allowed to become obese or smoke. If they do, they should be put on suspension or retrained. And the medical training itself should change. It makes a ridiculous statement about their ability to care for another, if doctors abuse their own bodies. Doctors should spend 80% of their time on prevention and educating their patient. They should be paid more to keep the patient healthy, than to try and cure him when he becomes ill. The whole system should be turned around. Maybe then doctors will be healthier and live longer and they can be models for us all to live healthier lives. That’s the ideal mission for a doctor…. a role model and a health counselor.

    • Kim says:

      Nice to know that you think doctors need to be perfect to be doctors. And what do you do for a living? AND, more importantly, are you perfect at practicing what you preach?????

    • Billie jo says:

      Or maybe people should care for themselves from the beginning instead of orbiting doctors for years and then expecting a miracle cute when it’s too late. Doctors are not God, they are human and most aste doing the best they can with a non compliant society.

  19. Thanks for this moving article.

    Perhaps there will be a gradual societal shift toward more humane intervention, including non-intervention when appropriate.

  20. Very moving and provocative post Dr. Murray.

    We should all have such a close relationship with our care-givers that we could have the confidence and trust in the exchange at these critical moments of our lives. I’m sure our care givers would want such trust and confidence with their patients when the time comes for that honest and caring exchange. It does make me long for the family doctor who visited us at home when I was a kid, who knew our whole family, and lived in our community.

    I’d love to see it as a book exploring the range of scenarios and daring to tease out the policy conundrum.

    The latter is the challenge to ensuring all of us the benefit of such a relationship, the protection from ill-advised care or outright mistakes, and the protection of providers trying to do what’s best for and wanted by their patients.

    We could use a comprehensive exploration of the entire process, one that examines the economic, legal, medical, and ethical issues along side of the real human life-death personal side you present here.

    I don’t see a simple answer but know the conversation must include all of these aspects and perhaps the solutions tried on a less risky and inflammatory stage than the one we’re trying to hammer it all out on now, the national policy and federal legislation one. This one can’t handle the intensely complex array of issues that come into play.

    I’d also like to see the dialog begin with the bedside scene you present, with the players involved including the families and build into the policy level rather than the other way around, hoping that the human side will sort itself out after the fact.

  21. ann tomlinson says:

    i recall the author of the All Creatures Great and Small series and all the “good cows pulling on their hay” and horses and sheep and such he saved because he was willing to do surgery and “get paid when i catch up” and if he didnt do it they would have sent 4 the knacker man (butcher) and that his babies were born at a midwife’s house (being a surgeon he kept his expectant wife away from hospital) and that he died peacefully at home from prostate cancer~i can honestly say if i were a man i would prefer to die peacefully at home and having seen Wit with the amazing Emma Thompson (nanny mcphee) i can say she did more to promote hospice and death with dignity than any actress of the 20th century:)

  22. nikki wright says:

    have a look at the story of Dr john pollock nz, he did his best in his last few months, rest assured he had his ducks in a row

  23. Thanks for being a voice of reason, at a time when loved ones are scared and ill-equipped to ask the right questions. We should all have more information to make the kinds of sensible end-of-life decisions you speak of.

  24. Ron Gaber says:

    This article should be the first one read and discussed at every medical school white coat ceremony/orientation in the country!

  25. Denise Poland says:

    This is so true..I work as an RN in an Interventional Radiology Suite..you would not believe the procedures we do on terminaally ill pateints..biliary stents…nephrostomy tubes…feeding tubes…its absolutely ridiculous..we are currently scheduling a terminally ill man with colon cancer for ureteral stents…when will the madness stop and let people enjoy whats rest of thir lives and preserve their dignity..I am all for if I am terminal..leave me the hell alone!

  26. blackjack says:

    blackjack
    Thanks for your contribution and I will use it for my school research that I am doing for this website.

  27. SubirKrishnan,MD says:

    Thank you very much for writing this article. I’ve been in these circumstances many a times. I agree with Larry “it is rare that a healthcare professional actually describes what many feel.” This post resonates with the feelings that I underwent as an ERDoc!

  28. when in Rome says:

    interesting article, thanks for posting. Quite depressing though :)

    The article lacks any sort of data, however. Also, in all honesty, although I do personally know someone who survived it by miracle, this Doc gives the example of pancreatic cancer. The truth is that pancreatic cancer is a whole other reality compared to say prostate cancer. Many serious diseases can be beat in many cases so why shouldn’t we fight?

    It’s also an issue of age and requirements. My sister in law died last year. She was told she had stage 4 breast cancer ten years ago and was immediately handed a hospice card and told she had months. Imagine that. She fought like a warrior for 10 years and in the process, because of treatment (radiation and chemo) lost almost her quality of life including going blind. This decline in quality of life was a process however with things really getting bad her last 12-18 months. When i spoke to her about 4 years ago, before I got sick, with tears in her eyes, she told me that she had to fight to so that she could be there for her kids as long as possible and to try and do as much as she could as a mother to growing children. Her doctors and her pastor constantly said that it was her fighting spirit that gave her, and by consequence her kids, more years. Her kids were so young when she got sick that in the end they knew nothing but a sick mother. But she still went to all their sport events, all their school events, took them to church, spent ten birthdays, Christmases and Thanks Givings with them and so on. They now have traditions their mother set and many memories of her including mostly good memories.

    Sometimes people in my age bracket have no choice but to fight hard and not because of what we need but because of what we perceive around us and what we feel responsible for. Getting seriously sick at our age is a different ball game in how we might react to it. I don’t think most of us in my age bracket have the luxury or desire to react as the doctor in the article.

    • John Ballard says:

      I found nothing in this essay suggesting that this doctor’s choices become normative for everyone. The idea of “choice” was underscored repeatedly. Some may find the notion of dying depressing. Others looking at an expensive course of painful options ending in death may find it liberating. Here is a link to a short story by an oncologist who knows the difference and how best to lead his patients to an informed choice.

      http://sunriserounds.com/?p=700

    • atlibertytosay says:

      I don’t think the guy is saying all people should just give up. I think you missed the point. It seemed clear to me, that when it makes sense to just accept that your time is near, you might end up with better quality of life than looking at a toilet and throwing up for 3 months and then dying. Of course everything is situational based on each person’s circumstances. I LOVED the article and hope that the idea that if Doctors tend to NOT put themselves through a lot of the crap that other patients go through, then people might be more likely to look at things through more realistic eyes. Great Article.

  29. Katy says:

    More Americans need to read this article. Please publish it more widely!

  30. GregH says:

    This says a lot about our education system as well. We’re content to turn out graduates who have enough “basic skills” to get by, but have no idea how their own bodies work, or how to think about their relationship with medical science. Instead they get their knowledge and attitudes from TV, and we wonder why they can’t make rational decisions about end-of-life care. We would do better with a more practical life model: being alive means we’re all going to experience sickness, old age and death. Nobody has ever been saved from this situation. Acceptance of this reality would go some way towards helping people understand their own priorities.

    Thanks for a thought-provoking article, Dr Murray.

  31. Siva says:

    HIghly thought provoking for me as Pulmonologist/Intensivist…we face this on a daily basis…drawing fine lines between aggressive and palliative cares.
    If there are clear directives then it becomes easy to counsel. But if it is vague..few people have the courage to firmly say that futile care should not be provided or continued. Everyone should clearly state their wishes for end of life care as they age. No one needs to die in misery if they don’t have to.

  32. Robin Shelby says:

    I had a POA and living will drawn up when I turned 40 for these very reasons. It’s not that I have a death wish but I fear the misery more than dying. That said I found lunasin and Reliv. My health has improved dramatically and my doctor has taken me off of almost all of the prescriptions that plagued my life. I got healthy and now enjoy a full and probably long life. Robin Leigh…author of Dear Daddy…WestBow press.

  33. KellieH says:

    Well said and well written. This describes so many of my experiences of working in the ICU and ER. I still look back and wonder if we did the right thing.

  34. Mihaela P. says:

    Dr. Murray, thank you very much for writing this article! I am myself a physician,though currently working in a RN capacity. The article really” hit home” because it reflects with an extreme accuracy my way of thinking on this subject. I am very happy to know that I am not alone and that there are other physicians out there who think the same way.

    God bless,

    Mihaela.

  35. Bmill says:

    Some truth here. Too much care happens often. However, this article has a couple of anecdotal accounts as supporting evidence. That’s not very strong. I could find 1000′s of anecdotal reports where some extra chemotherapy or radiation gave patients a little longer to live in good quality and spend that extra time with their families. And, I’m sure there are stories of people who initially want to do nothing having some complication that could have been avoided had they done an extra measure. It’s not all as clear cut as this article makes it out to be.

  36. BruceL says:

    One thing is not mentioned here. Doctors have no problem getting as much powerful pain relief drugs as they want, but the rest of us (unless wealthy) do – the medical profession seems unreasonably anal when it comes to prescribing effective pain relief. When they express concern about the fact that they might be addictive for a terminally ill patient, all you can do is just shake your head …

  37. ashim says:

    An answer to this issue exists: A validated program from a Wisconsin hospital sustem that gets outpatients to fill out polsts, improves pt satisfaction and saves money:
    respectingchoices.org

    If you are interested in makong change, they can help you pilot a program at your institution.

    Lets educate ourselves as providers so that we may better serve our patients. Here is a site w 1 page fast facts w evidence based knowledge on pall care topics, like prognosis after acls. While financial incentives are perverse, the providers interested in proffessional and ethical care will want to know existing data and act accordingly:
    http://www.eperc.mcw.edu/EPERC

    I am grateful for this discussion, as I think we can serve our patients and ourselves far better when it comes to end of life care.

  38. NicholeICURN says:

    Fantastic article. After many years of nursing, I have never envied an MD’s task of being the “messenger.” But, I do make a point to be present in MD/family conferences, so that I may later translate and reiterate the information.

    “How has it come to this—that doctors administer so much care that they wouldn’t want for themselves?”

    Let’s not forget the “ancillary” staff involved. Where I work, it’s the RNs who poke, prod, and generally create suffering in the name of healing for 8-12 hours per day, who have high rates of burnout and “vicarious traumatization.” It’s the RTs who turn off the vent and take out the tube; it’s the OTs who stretch and bend painfully stiff limbs; and again, it’s the RNs who are first in line for patient advocacy, but are sometimes the last to be heard. There is nothing as trying as hearing a family member say “he wouldn’t want this I know it,” but then see said family flip a 180 when the white coat walks into the room. Ask any ICU RN about their wishes; you’d find an answer just like Charlie’s or Torch’s.

    Thank you, Ken, for your perspective, and your amazing essay. It is refreshing to hear it from a “white coat” (all respect intended.)

    • Another RN says:

      NicholeICURN, you said that perfectly. As much as I appreciate this article-and I do-the only reference to a nurse has a negative slant. Sometimes the entire healthcare team would strongly support the decision to “pull the plug” on a patient, but are at odds with a family who, for whatever reason (and often I think the reason is that they are incapable of seeing things as we do, because they have not had our experiences) and is unwilling to let go. It is the nurses who must provide the futile care to the body, even if it is morally distressing for them to do so. It is nurses who provide and coordinate hospice care, with much more autonomy than nurses have in the hospital setting, and the mission of hospice care is to make dying as humane a process as possible.
      I also wonder, if so many doctors feel this way, why are things as they are? Doctors may hope for themselves to go gently into that good night, but I’m skeptical that it is always what they want for their patients. It would be very difficult for an oncologist, I would think, to go to work each day with the mindset that they were going to just diagnose and send most of their patients home to die. They want to treat their patients. They want to find cures. We all want to hope that people will recover even when the odds are not great. And if patients die, does that not on at least some level feel like a personal failure? I think most physicians are motivated to try their hardest to cure their patients rather than just let them die. Nurses have always had a focus on quality of life and death issues, so it seems inappropriate to leave them out of the discussion entirely.
      Great article!

  39. dklanoue says:

    I have been a hospice nurse for the past 12 years. I have seen both sides aggressive treatment and no treatment, patients and families are more prepared and equiped to deal with death with no treatment, why, they have had quality time not quanity. Aggressive treated patients and families are over whelmed due to the side effects of treatment(s). Aggressive treated patients have run to appointments, suffered through the treatments, increased medications to deal with side effects of treatments and the caregivers have been that, caregivers, not parents, wives, husbands or children. Many patients have stated had they known how it would turn out they would have taken quality over quanity, why, because quanity rob them of relationships and good days. Those whom chose quality have expressed good comments for the time they were able to continue being part of a family, the good days they were able to share. They have commented they knew the time was shorter but it was better without all the medical treatments replacing memories they were able to leave their family. I lost a dear friend last year to breast cancer, her family had her to chemo the day she died. She had a heart attack while receiving chemo in the name of longer life, possible cure, her sons last memories are not what they could have been…society needs more education because the sad fact is…if the aggressive treatment doesn’t cure you, it makes you wish you were dead.

  40. This article should help all of us to think more deeply about the kinds of care we want at the end of our lives. We do not have a choice between dying and not dying. Rather we have the choice between dying one day rather than another. See my free on-line book: How to Die: Safeguards for Life-Ending Decisions: http://www.tc.umn.edu/~parkx032/HTD.html

  41. A.K. Guy says:

    Just a little note to express my support for the practice of CPR. My 63 year old Dad collapsed on a tennis court during his first match in the Senior’s Games in St George, Utah in 2010. His match partner and a player from another court administered CPR for approximately 15 minutes before the ambulance arrived (no AED on site, unfortunately). He was stabilized at the hospital and had 6 bypasses performed 2 days later. Without the critical interventions performed by the medical staff, he would be gone today. Instead, he’s back skiing, golfing, and even playing tennis in the same tournament again this year. He’s the best grandpa ever, and I don’t know what we’d have done if those first critical responders hadn’t performed CPR.
    We are Canadian and were completely overcome at the high quality of care he received in the US. Thank goodness for insurance.
    Wonderful article.

    • ICUNurse2 says:

      A.K Guy: this article is not about a person who is in an acute trama, that needs live saving resusitation to reverse that trama. This article refers to persons who’s expected outcomes are poor at best. (Let me preface this by saying that, i am thankful for you and your family that your dad recovered and is doing great! ) But if your dad’s outcome was poor, if the best he could hav hoped for was living as a shell of who he was, having to be cared for 24/7, in contant pain, unable to feed himself or even eat food at all. to urinate and deficate on himself, to loose control of any decisions for the coarse of his life, and suffer this way for days, months or years, would HE want that for himself. This is what the article is about. It breaks my heart daily to see these type of patients and be forced to participate in the torture they must endure because either they or their family have no idea what is in store for them. I pray for each one of them to find peace, comfort and acceptance.

      • A.K. Guy says:

        I think I understood the article quite well, thank you, and I would argue that my father’s expected outcome on the tennis court, in the ambulance, and after arriving at the hospital was probably quite poor. Since it didn’t end up that way, we are extremely lucky. He would not have wanted to continue a life without quality, of course, but our consent to the procedures that did have good outcomes were informed mostly by hope, as we were aware of the chances. He did have a few broken ribs and a painful road back to health, but if you ask him. he’ll tell you that it was worth it.

        • MD in Indy says:

          I think you’re still missing the important distinction between the futile resuscitation of a person with a known progressive and incurable illness such as metastatic pancreatic cancer, and a potentially reversible illness such as coronary artery disease, which, even though it may be severe, can still result in a good outcome.

          This article addresses the former category; your father was in the latter group. That’s the difference between “medically completely incurable” and “critical but still potentially reversible” illness.

  42. Kathy says:

    Thanking Linda, my high school friend, nurse, who shared this article and the author.
    just
    a
    high school teacher

  43. carybenn53 says:

    Amen to this…..let me spend my final days floating in the ocean, peering down through my mask at the wonders around me and, hopefully with some dolphins passing by. Let me enjoy the warm sunshine and let my ashes be contained in an artificial reef base to help replenish the those reefs that I love so well!!!

  44. B. D. Colen says:

    Having spent almost two decades covering bioethical issues for two of the nation’s leading newspapers, and having reported extensively on issues related to death and dying – from Quinlan through Kevorkian, I don’t doubt that there is some truth in what this author reports. However, I have to ask – where’s your data? Stories friends tell us are folklore, not facts.

  45. Tyrone says:

    Now I see why so many doctors are opposed to bureaucrat-run healthcare.

  46. B. D. Colen says:

    I wonder what you mean by “bureaucrat run healthcare?” Surely you aren’t using that as a euphemism for government run health care, because we’ve had “bureaucrat run health care” ever since the wide spread introduction of employer-based health insurance after World War II. Private bureaucrats, whose only motive is improving their financial status and that of their executives and investors, have run our health care system. Perhaps it’s time to give government bureaucrats a chance to run it – for everyone. They can’t possibly be as bad as the private bureaucrats. After all, Medicare has far lower overhead costs than private insurers, and most Medicare beneficiaries are pleased with Medicare.

  47. Diane Charmley says:

    As a retired RN, who has worked with adults and children with cancer, I often tell and have told my fellow health care workers, that I will not seek intervention and will focus on quality time with friends and family. I have watched so many parent and patients fight to last minute, but the one dying is left suffer to meet the needs of the living. Sometimes, too, its the fault of the MD who leads them on, and is too egotistical to tell the truth, that he can not save them from the inevitable. I prefer to got out like a dance and as I run ..finishing with a smile on my face. I may need pain meds to smooth my way out , but I have no desire to support the pharmaceutical companies or corporate sickness care.

  48. A Melikian says:

    Thank you to Dr. Ken Murray for writing this article. It is so long overdue. Well stated, level-headed, and sincere, he expressed what we all want to say about our medical system and our life and philosophy as physicians. Will spread it around.
    Adrien Melikian, MD

  49. D. Mesick says:

    Dr. Murray,
    Thank you for putting on paper what most Long term Care Nurses want to say to family members. I cannot begin to tell you how many times I have witnessed residents being kept alive by family members, only to watch the resident suffer. I really wish there was a way to explain to family members what exactly they are putting their loved one through. Sometimes I find the family members are not ready to let go of their loved one and that they are keeping their loved one alive for themself. As an RN with almost 20 years experience in Long Term Care (LTC) I feel as though, since I cannot educate a Alzheimer/Dementia/ MR or unconscious resident; our society leave these decision up to the resident’s family members that determine when to say enough is enough. Unfortunately even when LTC residents have advanced directives and Living wills; many times facilities and MD’s will err on the side of the families’ wishes; especially with a confused resident; as the world ever so progresses into a sue happy society, MD’s, medical practioners and nurses are forced to err on the side of caution. Great article, now if only we could get long term care (TLC) residents and family members to read it and get them some education perhaps the Medicare System would not be in the dire straights it is now. I know that sounds harsh, but I am a firm believer in advocating for my residents and following their advanced directives/ living wills and honoring their wishes. It is So, So hard to sit back and watch as some families make poor choices for their loved ones and feel helpless (Nurses get sued too) because we have to be very cautious on how much and what we say. CPR is another story, as one gentleman stated above, it does save a few lives, this is why medical professionals are trained and perform it. However, a 63 year old man verses a 95 year old with co-morbidities and no quality of life is another story. I see it daily, it is heart breaking. I learned early on in my profession, especially working with the elderly, that these LTC residents know when they are tired of living and know when they are ready to reconnect with their loved ones in Heaven. They have told me, many times: “Deb I’ve lived my life, I am tired, I am tired of not feeling well and I am tired of living”, and these are not Depression patients). I only wish they would tell their families this, they WON’T. Why:. because they fight to stay alive, not for themself,but for ther iloved ones…..
    Thank you once again for this article, unfortunately I don’t believe the information will get to the people that really need this education; the patients (residents) and the family members.
    Sincerely, D. Mesick, RN, BSN

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