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.

443 Responses for “How Doctors Die”

  1. ICUNurse2 says:

    As a icu nurse for the past 20 years i have observed several things. 1. the doctors are rarely upfront about long term outcomes for terminal illness. 2. The patents wishes are overturned daily to prevent “the family from suing”. 3. If the doctors were actually upfront about what the patient can expect and how futile some treatments are, the families get angry, and refuse to listen. and last to prevent all of this, EVERYONE should make their wishes know to their family, and the md. It should be discussed in no uncertain terms what you want, long before the question of what you want is needed. And your wishes should be followed.

    • kelli says:

      I am a RN of 30 years that right now is sitting with my mom in her home while she is under hospice care. She will die today of that I am sure because she is unresponsive, no urine output for 24 hours, febrile and not swallowing. It is awful to watch your own mom die but it has been worse watching her repeated hospitalizations that never added to her quality of life. She has lived with heart failure for too long and her poor, tired heart is done. I am just keeping her comfortable with morphine right now. I have already discussed with my children my wishes since I do not want to prolong a life that has no quality to it. I think the doctor in this article is on the right track. Live out what you have left with quality rather than being a prisoner of your home, oxygen, meds, pain, breathlessness, and depression. As a nurse I have seen it too often. Not saying there is no such thing as hope, but there is also facing reality. My mom’s doctor was always honest with her so she was aware of the terminal aspect of her life but 911 was always called on her when she crashed to try to prolong her life. I do not want to live my life like this and can see the doctors viewpoint. Everyone has to do what they feel comfortable with but the unbelievable amount of money spent on prolonging life when it will make no difference is bleeding insurance. Patient education has to be more universal to allow for better choices to be made that are more realistic. For now, I am praying for my mom to have a peaceful quick death and be free of the suffering. I will miss her greatly ,but not watching her suffer and deteriorate as she did, being beaten down and defeated by a disease with no cure and no future.

      • Danielle says:

        I lost both of my grandparents to lung cancer (my grandma also had congestive heart failure) in the last 4 years. Both chose hospice care. I’m grateful for the help and support hospice gave my grandparents, and the help and support they gave me as a caregiver.

        I’m sorry you are losing your mom. May she rest in peace. And I wish you peace and comfort at this time.

        At least we can say they did it their way, right?

      • karen says:

        I wish for a peaceful end to your mothers life. I just lost my mom after agreeing with her that she should have surgery to repair her aortic valve. She did not survive. She died peacefully, but I hate that we put her thru that. May your mothers memory be for a blessing!


      • Kelly says:

        very sorry for your loss, I also sat with my mom while she passed from cancer she slipped into a coma and and passed 2 days later…

      • Lori says:

        I am an RN as well and watched my mother die from leukemia. She was 80 and decided against chemo, anything radical treatment. It was the hardest thing for me to do was watch this vital woman slowly sip away from me. Wither away to nothing…but slipped off peacefully one day to join my beloved Daddy in Heaven. A man she has been without for 30 yrs…she was ready to go.

      • mdtyper56 says:

        I went through that with my sister with lung cancer. She slipped into a coma and passed on peacefully, in NO pain, which was all she was worried about, not dying, but she just was fearful of the pain. Many hugs to you as you go through this with your mother. May God wrap his loving arms around you and her through this.

    • Beth says:

      This has nothing to do with how doctors die. I agree with the above comment. . Even though this man prolonged survival rates to 15% as a physician, that 5-15% to get to five years doesn’t describe the course for metastatic cancer (stomach lump and it’s pancreatic). Fifteen percent with what treatment they will be undergoing is a catch 22. If it was quality time, so be it. This also got my attention; why does an orthopedist work on something for pancreatic cancer? Weird. My guess is he knew it was his time and chose wisely. Just as some of us other cancer patients do. Doctors DO die like the rest of us! This article is about patient, physician or average joe citizen, end of life care.

      • David says:

        It wasn’t the orthopedist that worked on pancreatic cancer, it was the doctor that did his exploratory surgery.

        I think you missed the point of the article, but it sounds like you agree with it anyway.

      • Laura says:

        The orthopedist was the one who got the exploratory surgery and was diagnosed with pancreatic cancer, not the one who performed the surgery.

    • doc says:

      Fact of the matter is nurses don’t have these conversations with patients/families. So it makes no difference to me if you are a nurse in ICU for 20 years because when you make blunt statements like “doctors are rarely upfront about long term outcomes for terminal illness”, . In fact in my experience, most doctors are upfront about long term consequences of terminal illness to avoid getting sued. All in all, it is not about getting sued, we are ethically taught to cater to patients wishes. Transparency has been shown to cause less lawsuits and most doctors are aware of this.

      Secondly, the patients wishes are not overturned to avoid getting sued. Thats a very superficial statement for someone who has 20 years of ICU experience. Their wishes are usually clearly stated in the chart. If it is not stated in the chart, then all efforts are made to understand what the patient’s wishes might have been from the family members so that the wishes of the patient can be honoured and respected. Clearly, as a nurse you do not partake in these discussions with patient and family and to make such statements is absurd by blaming doctors.

      • orly says:

        Rebuttals tend to be more effective when they’re not made personal and hurtful, it doesn’t make your point stronger it just makes you look like a jerk. Blanket statements really don’t work on this topic, because of the human element in the equation. Different things can can happen for the same situation depending on location and care givers.

      • RN says:

        Many doctors do have this crucial conversation but aren’t at the bedside after the patient or family member has had time to process the information and have questions. As a nurse I have had these conversations with patients and families many times. Having said that there are physicians who will not discuss the consequences of terminal illness with patients or their family members. Whether it is because they feel like a failure if they “let” the patient die or they really feel like they can improve the patients quality of life, I’m not sure. I do know that every patient deserves to have this conver

      • Jake says:

        You are obviously a very defensive doctor. The nurse was was not blaming you. She was just explaining very casually, that patients family are usually the ones who inflict that kind of suffering due to their stress. The “not getting sued” is just a blunt synonym for “ethical”, because she was writing her comment while feeling slightly agitated at the current state of affairs. You don’t have to be too worked up.

        Secondly, your counter attack on nurses on “Fact of the matter…” makes you totally unprofessional and disrepectful. All just because you want to defend yourself. I would expect doctors to control their emotions better.

        I think as a doctor, you should work on listening, understanding and comprehending others. It will help make you a better doctor.


        • Stef says:

          Good statement Jake! Very true! Doc- I have a lot of respect for physicians- and being the one to actually tell families their options must be really difficult. As RN’s we do not have that role- but “RN” is right… we are the ones who spend 13 hours day with these families. They trust nurses because we are forced to establish relationships with them. We do have a lot of conversations with them regarding end of life and understand their true wishes. It has been bc of nurses urging physicians to have honest conversations with families that many of my patients have been able to die with less suffering and more peace.

    • Rod Williams says:

      Born in the summer of 1942 I am not in the medical field but in the summer of 2004 I had an aneurysm in the basilar region of my brain, Dr. Robert Spetzler did the procedure that kept me being a mammal for a while longer, I had no previous medical history other than a hemorrhoid in 1967 and again in the Eighties, that was it. I spent 7 weeks in the hospital because of the stroke, 6 without recognizable memory, I did not know wife and children and have no memory of those weeks. I was without memory just long enough to lose my physical addiction to tobacco.

      The day wife was told by the hospital to find a suitable place for my 99 lb carcass, down from 131 lbs, that very night my memory made a connection. It was very dark, there was moaning around me from time to time and I had to pee rather bad. I pushed the help on the corded remote, no response, I yelled a few times, I was zipped in a bed with a nylon net over it and could not get out to find a bathroom. I screamed a few times as well and since no one came I decided that since the yelling was making me thirsty and I had no water I wadded up the top sheet in the bottom corner of the bed and peed on it then quickly and easily went back to sleep.

      The next morning someone noticed I had remembered something so they kept me another week, gave me a release with my next appointment in 3 years which I cancelled in plenty of time. I have not had a pill since the fall of 2004, I do not use tobacco or alcohol and a lightweight on caffeine. The last pill I took was Dilantin which dilated my blood vessels so that a clot would slip through and the side effects were basically killing me. Dr. Spetzler said I could quit and also said, when asked that hard work does not cause strokes. II found that THC, the active ingredient in Marijuana also dilates vessels without the nasty, nasty side effects if Dilantin.

      I was made unwelcome at stroke support for passing out fliers suggesting that we use pot to dilate with, didn’t go over very big back then but now the head of the neurosurgery ward, Dr, Frey suggests it to patients.

      You do not know what constipation is until you’ve taken Dilantin, I went to stroke support to help others who had a stroke and since I had gone through one, I wanted to share. I have no paralysis, I became ambidextrous in the early Eighties from performance skating and Marathon events. I eat healthy, brown rice and etc.

      Being a human mammal is interesting but would not want to make it a habit, I believe that when a human goes past peak that we think about making room for the children and grandchildren, Unfortunately our world is not the best of places and we don’t like leaving our children even though we made them without a thought as to what kind of world we live in, Just stupid humans I suppose. LOL Shedding our flesh is natural as well as necessary as if we remained a mammal for hundreds of orbits, if you think our world is bad now, ha… it would be more terrible if we didn’t chuck off our mammal skin. Mother Nature has the best medicines and if you accept Her, there will be no pain only pleasure. When we disconnect from our mammal form, the laws of energy say that from the sudden weight loss, our vibration shifts to the next logical step to a frequency that the human mammal cannot see. Some would say, Free, free at last. Others may freak out because they were not shown in their early period that this is natural, Nature at work and we should accept.

    • Rod Williams says:

      We as a world need to change our attitude about remaining a mammal for as long as possible. We can do this through education however a big stumbling block is religion, a belief that a higher power who has always existed had an only child from something it made for the express purpose of being tortured to death and in the event the son really didn’t die then change that to ‘traded location for the sins of the people’. In this logic, 2 and 2 makes 0. I prefer ‘had a bad weekend for our sins.’

      I believe that being a mammal is important, for the development of new life, the nulls. Yes when we are born most of us are nulled. In many cases our parent can tell us all sorts of things and they go in one ear and out the other. So living on a piece of spinning rock is the answer? Must be.

      You realize that we are energy and what isn’t will shed. Dump our carcass. Unfortunately our cadaver does not go to help replenish the planet, some are even too full of pharmaceuticals to do it any good. In our ignorance we fill the cadaver, we give the cadaver its last alcoholic drink, we call it formaldehyde and the earth hates it, not a good way to disperse industrial waste, poisons the planet just as does Roundup which is also industrial waste. The earth has feed us all of our lives and we don’t even have the courtesy to share. Fooling Mother Nature is a bitch, she pays back in spades. A good green natural burial is the best. Feed her so that She may feed us.

      I was born in the summer of 1942, I am coming up on my 71st orbit of this strange planet, had an aneurysm taken care of by Dr. Robert Spetzler in Phoenix in 2004. I could call him Robert of ‘Bob’ I suppose, he’s the only man who has had his hand on my brain, plus I’ve met with him several times. The experience to me was wonderful, the aneurysm was grand to say the least. At 6 weeks of my hospital stay my wife, friend and mother of our 9 was told to find a suitable nursing facility for my 99 lb suit of flesh down from 131 when I was admitted at Barrow. Several weeks in ICU I was sent to rehab, I had no conscience memory, I did not recognize family,

      The same day, into that night my memory made a weak connection and I had to pee really bad. I was in a nylon webbed bed, there was a small light on a corded remote for help. I could not get out and there was moaning all around me. I have a part that Doctor Spetzler designed in my brain. Maybe I should call him Bob.

      I yelled for a while still having to pee and then just a few times I screamed, Help. I realized that yelling was making me thirsty and I did not see water in the blackness of the ward I was in. So like any good boyscout and not having a clipper to cut the web and escape, go home, 2 miles away, I wadded the top sheet in a tight ball in the far corner of the bed and whizzed on it then lay down to easily go back to sleep. Dr. Bob had his fingers in the basilar region of my brain.

      I have not taken a pill since 2004. My charming wife whose father is retired USPHS Atlanta, when she found out that doctor Sally started me on Zoloft I was weaned and by the time I left the hospital I was taking Dilantin,. to be cont.

      • Rod Williams says:

        Dilantin was sure enough dilating my vessels, I was taking several 100 mg capsules each day, maybe 4 times a day, no longer sure but I am not a hater but I hated those things, they were killing me. Sure the chemical was noted for dilation of vessels in the mammal but at what cost. I not only read the side effects, I took them for 4 months, finally got strong enough to make an appointment with Dr. Spetzler for advice on me again operating a motor vehicle which was important to my work. I work puzzles.

        I was given various right/left tests by an assistant while Doc Spetzler and I were talking, I asked: “can I quit taking Dilantin?” His immediate reply was , “Yes” then my lovely wife chimed in, “I’ll wean him.” at which time I am thinking to myself, “oh crap”. I cheated a bit, I was tired of being totally constipated plus no sense of taste or smell and I was supposed to eat to put mass back on my 5’6′ frame. They wanted me to become a mammal again and I’m once again thinking, o crap. I walked the 2 miles home from that just to see if I could. I did, a little tiring thought.

        A few months later at a NORM pot luck in the park event, I was playing Frisbee with a group showing them that using both hands if best, I showed the group that being ambidextrous is like having a helper and can be achieved by everyone. I was on a hill and someone threw me the Frisbee, I ran for it and leaped out, running down hill and I could not catch it, heading for the ground and I hit and rolled and came to rest ready to spring up. It was great. I also show the group that bowling both right and left was optimum for a healthy body even if it is temporary,

        Damn good thing that’s this mammal life is temporary.

        By the way, the active ingredient in the female Marijuana plant is called THC which DILATES our vessels and DOES NOT have the side effects of killer Dilantin. Approve marijuana, relieve the stresses of a world gone insane because we are running, every major system is out of sync with reality. LOL Not really funny, well crazy funny maybe.

        One thing I will say, Planet Earth is a damn good, first rate Character Generator for new life, for kids who did not listen to their parents. In reality there is really nothing that can hurt us. With Mother Nature on duty always, it’s a shoo in from this mass gathering frequency to something that makes more sense, the Next Logical Step if you will

        One last comment, we can and have learned a lot for other mammals such as Dolphins, from all life really but the dolphin is matriarchal in nature. The dolphins are intelligent enough to understand that being female of the species is 420,000 more difficult than going through a human life as a male. Consequently the female, rightfully so lead the pod. Pain is Gain, not Might is Right.

        • Rod Williams says:

          An addition to the above, also I asked the Doctor during the ‘can I drive again’ checkup, “does hard work cause strokes,” Dr. Spetzler immediately said, “No, not at all.” I had to ask him as I love working, I could be considered a workaholic.

          I quit tobacco the day my head felt all swirly and I felt sleepy back in the summer of 2004 while my stroke was gaining ground, I was on a porch planning my daily activities trying to roll a cigarette and the tobacco kept floating off the paper, I had to give up from increasing sleepiness, I had been a tobacco smoker for most of 45 orbits.

          After being without memory for the 6 weeks, when I woke up and had to pee while in the death watch ward. I no longer wanted a cigarette, I had lost my entire physical addiction. That alone was worth the half million that JFK’s National health care paid for. I haven’t smoked since.

          I quit alcohol in the early Eighties and I am a lightweight on caffeine though I do allow a son to burr grind some Columbia bean and give me a small cup once a day at which time I give him his daily bread, a portion of what I have earned that day or week, Some time I pass on the coffee after drinking a Mexican made Coke Cola with the cane and without the high fructose corn sweetener.

          We humans need to get over the fear of losing our mammal body, doing so is not only natural but necessary.

          I agree being sued sure changes a lot of policy insluding price structure, maybe most of all.

          I’ve never sued anyone in my life and if Dr. had slipped and the aneurysm clip had slipped off, I wouldn’t blame the man, I’m sure he tried his best, errors do occur to all mammals, from airplane mechanics to neurosurgeons and I really do believe that it’s usually for the best. I see evidence of other energies of a totally non religious nature around, I do believe in miracles but stemming from our family thread of elders who had paid attention and graduated to the next logical step with honors. There is intelligence in the universe, just not a whole lot on this spinning piece of space compost that we ride on.

          One of the most idiotic things is that humans were led to believe that the number of orbits they have made around the center camp fire of life, that’s how old we are supposed to act as in acting our age. Time is like a chain link that we gladly wear around our neck so that we can have birthdays and other made up nonsense. Yeah, it’s really great to be a mammal, sure it is. LOL

  2. Beth says:

    Thank you very much for this wonderful article… It addressed issues that I have tried so hard to communicate to my family… I am a Respiratory Therapist… I know not the usual title of Dr or RN or anything like that but what people don’t realize is that respiratory is the one that’s there in traumas, ICU, we are the ones breaking those ribs during CPR, we are the ones managing the ETT to secure that airway, we are the ones managing the ventilator that is keeping that person alive…. We are the ones that they call to turn the machine off to let someone go, we are the ones that transport to do that brain flow study or the futile MRI’s that aren’t going to tell you anything different than the one the day before… It us so hard as a professional in the field and that close to the end of life aspect or where the emergency decisions are made to try and explain to someone that hasn’t seen what you’ve seen or taken care of what you’ve taken care of to understand what you are saying when you try to discuss your own end of life care or the what ifs care…. Even after careful explanation, unless you’ve been a healthcare provider of any sort… It’s hard for the rest of your family to understand or except the decisions your trying to put forth… What bothers me the most I guess is that even though I have made my wishes known… Even though they are documented… That they can still be overridden… That the next of kin or medical power of attorney can change it… And what breaks my heart is that I know if I were in a car accident tomorrow and brought to the hospital they would say “do everything” without stopping and looking at the outcome… If I’m not going to be ME or have any kind of quality of life than just let me go…. And if I did come down with some kind of terminal illness. I wouldn’t want to be spending my last months or money that I could leave to my family on futile care… Comfort care, yes I would want to not live my last days in pain but to prolong it just feels inhumane… I sit with some if my patients… Just holding their hand sometimes and pray for them to pass so that they would not ne hurting anymore… I’m soo soo sorry for the rambling comment… I never comment on anything… But this pulled a heart string that I feel deeply about… Thank you So much for a wonderful article!!

  3. Christa says:

    I’m not in the medical field at all, but I totally agree with this article. I didn’t tell my dad, but when my mom had a massive stroke, I prayed for her to pass quickly, because I knew that if she didn’t, he would want to do “everything”, in the hope that she might wake up, but she had suffered so much brain damage that that really wasn’t a possibility. Even so, he would have spent his last dime, and never left her bedside, hoping. I don’t want that to happen to me. I don’t want them to declare me dead prematurely, in order to harvest my organs, (I have a donor dot on my license), but if “I” am gone, let me go. I’d rather die on my farm, and have my ashes scattered here, than suffer in a hospital for an indefinite time.

  4. Paulo Ramacciotti says:

    Congratulations for the nice words… I live in Brazil, and as a physician it is great to read an article like this, that gathers all my beliefs and experience about this special and time of life, and that surelly should be treated in a more respectfull way than it is: our deaths…

  5. Judy says:

    I have spoken to my doctor and have a medical directive regarding extended care. I have also spoken to my family. Quality is so much better than quantity. I know where I’m going after this life is complete. I look forward to seeing my family again. Thank you for this article. I agree with it completely.

    • Kim says:

      My husband and I both also have directives that say specifically we don’t want to be put on life support, etc, should something happen to one of us, But I also think its because we also know, like you, we will see our families again, and know where we will be going in the next life. What a comfort that brings to us and our families! This was a great article!

  6. Liz says:

    As a nurse, I like to think I will go as Charlie and Torch. After 40 years of watching people decide their options I’ve learned that none of us really know what we will do until it happens to us; whether we are medical people or lay people. Doctors are healers by nature but even in cases of poor prognosises, families don’t understand and need time to adjust so for that reason it’s not always that the doctor wasn’t upfront about poor outcomes, but families can’t always hear the truth.

  7. As a person who has suffered with pain and health issues for 55 of my 60 years, and given my ETA fro death do to COPD and other factors, I am sad to know No one will be there for me to stop the medical professions abuse of my mind, body and emotions. I have seen my mother suffer before death, and my father. No Code Is not enough to keep from needless suffering. It is time to treat humans with as much compassion as we treat our “pets’ I know the US is no super power…but saddens me we are still in medival times.

  8. Martin Cosentino says:

    Dr. Murray, such a heartwarming and kind approach to the steel edge of today’s medicine. My father-in-law, a retired chief surgeon at a large Cleveland hospital, suffered a stroke and was hospitalized for two weeks. He had discussed these medical matters with his wife many years previous, and she was aware of the DNR requests he had made of her. About 5 weeks after the stroke, he suffered a cerebral hemorrhage and went into a coma. There was no saying of goodbyes for his children, and the doctors explained why. His wife gave her consent to turn off the switches.

    We have been seduced and charmed by the machines and the technology, and the trust and confidence we once had in the doctors’ judgments and skills has given way to a ‘plug them in and everything is allright’ placebo that only painfully delays the inevitable. I can only hope that thousands of doctors metaphorically ‘disconnect’ themselves from the mechanical medicine factories we run in the US today. That the illusion of machines and sometimes hundreds of thousands of dollars does nothing to deter the end-of life we all must face, is a lesson in stoicism we desperately need. It speaks of a strength that not only aids us in the everyday living we move through, but the final endurance we will need, not only for our loved ones, but ultimately for our very own selves.

  9. Burt Goldberg says:

    It happens to researcher in Medicine as well. I am Professor of Biochemistry and Research Professor of Molecular and Biochemical Parasitology. Went las year for a friend to given me my flu shot. He realized i was very sick and anemic. Next thing I know I have a diagnosis of Myleofibrosis and having a 7.5lb spleen removed and a bone marrow transplant. I am very luck and have had exceptional care (MSKCC) by my doctors and especially the angels on Earth, my nurses and N.P’s. With out their care and allot of luck, would not have just celebrated the new year and returned to my department and lab today! By the way how do you say thank you to tow enormously special people, a friend who cared and got a rare diagnosis right, and a person so generious that she donated her bone marrow so i am alive today.

  10. Annmarie RN says:

    Amen! This article should be posted in every waiting room in every hospital for families to read. Knowledge is a very powerful tool!

  11. Jan says:

    A very enlightening and honest article. But, I am upset about one thing–the nurse who reported the MD for “pulling the plug”. That nurse should be disciplined and have her/his license put on probation. I have been an RN and CRNA (nurse anesthetist) for many years and know that the fear of pain and loss of dignity are prominent in the minds of those who are dying or have debilitating chronic diseases. It is the nurse’s job to comfort the patient and to be responsive to the patient’s requests. No one has the right or the qualifications to play god.

  12. Victoria says:

    I have been a hospice nurse for the last 4 years. My first hospice patient was an 82 year old doctor who was dying of renal failure and prostate cancer. During the admission process his wife told us that when he realized he was no longer treatable, he gathered all of his family together and told them he was dying. He told them he would grow weaker, sleep more, eat less, and occasionally be confused. Then he would likely slip into an unconscious or semi-conscious state and die. He told them not to be sad, because this was the kind of death he had prayed for every day. He told them that he wanted them to make sure he died in his bed, with his dog, and because he had this discussion with them, that is exactly what he did. I had worked in infant critical care for 13 years prior to that and had experienced every kind of horrible, drawn out, painful, undignified kind of death that could be inflicted on a baby in the attempt to save them. This man’s serene death had a profound effect on me. We have somehow forgotten that living longer is not always the appropriate goal.

  13. Imegahan says:

    We the public are misinformed. We go about our daily lives, hearing snatches on medical miracles, and so formulate an unarticulated belief that should the need arise we will ask the fairy god doctor to wave a scapel (or laser, or such), grant our wish (for extended life), assuming this means something like what we’ve always known.

    Farrah Fawcett was lovely, brainy, and brave. She did more for availing the public to the real side of sickness, decline, and death, than I ever knew was possible. So often we glorify the process of fighting to the last breath, like it’s all akin to Chariots of Fire, or Rocky, or some other David and Goliath story. We put on the boxing shorts and gloves, because we do not know how to die (let go). We need to become informed now, when there is no crises, and we have our senses; and we need to make an educated informed choice. Thank you.

    • Rod Williams says:

      I was born in the summer of 1942 and in 1969 I became aware of what we human mammals call death, I was staying in New Orleans and one night thought I was dying and I was so afraid, I near panicked, I pulled several hunks of beard from my face thinking about dying. “Oh no I thought others die, I don’t.” Then I thought some more and actually ran from death . If was the scariest event thus far in my life and at the time but as I gave it more thought became one of the best. I worried about death for for 7 years and in 1977 finally I lay down and accepted it, lock, stock and barrel, I was tired of running. I remember that night well, like yesterday. As soon as I accepted what I though was death my body relaxes and it was like an explosion, it was wonderful, I felt so alive. I had accepted giving up my mammal body in the core of my being. That has changed my thinking and my life for the better.

      In 1988 from deep physical pain I went into shock and I was floating off, no more pain, rats could have been gnawing my face off and it would only tickle. I was shutting down from my feet upward and really liking what was happening, I did not panic from my previous experience, I was ready.

      It was early in the morning and and I hear wife say, “Oh you don’t look so good.” so I said, “okay put another pillow under my feet and another blanket, I will be back. I remembered our 9 children though she wanted 12.

      I really did not want to come back to this dimension of flesh, of being a mammal on a sailing rock that’s orbiting a large nuclear furnace then counting them so they will know what age to act.

      I think of that experience often, it was wonderful, no pain only bliss and I loved it, Mother Nature is so gentle.

      Then the aneurysm in the summer of 2004 and the 7 week stay in Barrow Neurological Institute. I have a part in the basilar region of my brain invented and installed by Dr. Robert Spetzler. It was a good experience, I have learned so much from it. More than I would have learned had I not had one. I didn’t feel near death during that experience though I was and going into it, knowing that something was happening and I had no idea what, I woke up in the morning, planning days events, it was a Saturday. I realized that I felt a bit tired and my head felt slightly dizzy. I thought about losing my flesh, shedding it right off this old energymemory pack is me. Losing the mass will allow me to vibrate to a higher frequency and finally be free of humans interference.

      What are the possibilities of life in an infinite universe? Is mammal the highest? Are we as human still evolving to the next logical step of energy? I hope so as there is only so much we can handle being in a world that is basically insane.

      Some could say that although being human sucks, this dimension is a good character generator for new, ignorant life such as we who came here either planned or unplanned. Being human is much like a Dungeon and Dragon Game as there are various keys to find that will release a heavy shackle that we wear on a chain around our neck. Our race of mammal have no right thinking that we are masters of this planet. That’s BS.

      All life in the universe has the same value, a 1 and all non life a 0.

      A main problem is that we think that we should remain mammals long past our primes, taking up resources that could be used for the young,

      Death came to me that night in 1969 from a hit of Purple Owsley that a friend flew in from San Francisco. A good life experience as was the time I went into shock and was enjoying it and my stroke was good also. Remove from memory any one of the experiences and I would be a shell of my former self. We are each a sum of our experiences.

      When I was taken to the hospital with lights and sirens but I missed it, I miss 6 weeks of memory, no clue, had 2 distinctive dreams and 1 awesome feeling, death never entered the picture. The hospital wanted my medical history, we had the same family doctor for the past 35 years and in that time I had gone 30 years earlier with a hemorrhoid. Doctor was kind enough to tell me how to get rid of them myself.

      I quit pills in the late fall of 2004, I quit smoking the day I started stroking, never smoked since. I gave up alcohol in 1982 though I only drank to celebrate real events like Mardi Gras’ , weddings and such. Not often still see alcohol as a toxic poison that destroys all life including plant. Alcohol is like a wrecking bar that big business advertises/pushes on the population like it’s god’s gift to the human mammal and someone gets killed or injured or hits a child. Bad stuff, should be a Class 6 felony to advertise or push any substance that is both addictive and has harmful side effects, just common sense. An intelligent society would not think of pushing harmful substances on the people, it’s just something that’s not done.

      I really doubt if anything in the universe can actually die, to cease to exist, I can see change which is a necessary constant. When we are big enough to say to our body, “get off me you pos.” lol. we will have graduated to the next logical step of energy and I have an inkling of an idea what that entails. Sorry for the typos, it’s in the middle of the night I couldn’t sleep. Use binary logic when figuring sums, it’s fast.

      • Rod Williams says:

        Death is make believe, made up by a herd of adult mammals long ago, the same with time. Energy cannot be destroyed, God is the title given for the first byte of lucid memory in the universe, She is the first, the eldest of all.

        Life as a mammal on a spinning space rock is much like being in a Dungeon and Dragon game. Find the key to a certain understanding, be given the key, lose a heavy link in the chain we wear around our neck. Lose all the links and vibrate to the next logical step where our multicolored aura does not support nor can support mass. Having mass to support, feed and stuff was fun for a while, think I’ll give the next dimension a shot, I have orbited the center star 70 times and in human mammal thinking, I’m 70 years old,. LOL Hee Haw. Imagine our age is the number of orbits we’ve traveled. How quaint,

  14. Pat. S. says:

    My father-in-law, at 80+ yrs, had a dire heart condition. They found colon cancer, which they thought might have already spread. They chose to take out the colon cancer, assuring the family that even with his bad heart, the surgery had a 99% chance of success. Success of what, I wonder. He lived a few weeks in agony after the surgery, bound with all sorts of tubes stuck everywhere, with a cocktail of drugs to keep his heart going, but not enough to heal the surgery, which ruptured. He was too ill for the drs to go in and repair it, and was in awful pain, the treatment for which interfered with his heart meds, so had to be used sparingly. I feel the doctors were just “playing doctor” with this patient, and it is criminal. Pop had to wait until my brother-in-law could bear to let him go, which I don’t criticize. But I do take the lesson, and will NOT let this happen to me or anyone I love.

    • Rod Williams says:

      In a more intelligent world we humans would realize that after prime is passed, it’s time to think leaving. If we all did that, the world would be so much younger today. Assuming that our children are a step in evolution, recognize that they are probably more intelligent but unfortunately our world is sick from running faulty programs for eons and leaving our children on their own even though we did not give a thought as to the condition of the world when we made them, now we don’t want to leave them in such a dreadful place.

      On another hand, if our world were wonderful, the children loved it and were happy here, we’d gladly depart without much of a struggle, Next time I see a 400 lb glob of humanity in a motorized wheelchair smoking a cigarette, I’ll barf. Why do most humans think that losing their mass is such a bad deal?

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  16. cass says:

    I work as a respiratory therapist in an urban Detroit hospital. It should be the patients personal physician that generally should speak to the patient. Thats a moot point for most of my patients as they use the hospital for primary care. I get so upset when end stage disease pts and family are asked do you want everything’ done. No one explains that “everything” means a teach and peg tube then off to a nursing home for a miserable death. Believe me their ARE worse things than dying. Wish we had. national definition for DNR status. Where I work you must be a DNI and DNR to allow comfort care. I think approaching a patient with the term comfort care would be so much better than do everything…

    • Rod Williams says:

      Good post. Shedding our mammal flesh is not only normal but necessary. Humans really fear losing their flesh and since we all will lose our flesh and if we spend a great deal of effort worrying about losing our flesh, we’ve partially wasted our mammal life worrying about something that is natural, normal and necessary.

  17. Ruth says:

    Our 82 year old mother ended up with CHF from chemo for cancer. She wanted the chemo. Mom knew all the risks. Her gentle, caring oncologist actually came to mom’s room and said she was sorry that this happened to mom. Fast forward after a month of hospitalizations and rehab mishaps. A doctor who had been on mom’s rotation and knew we would peacefully accept hospice when the time came, said to me one day, “We’ve already almost killed her twice. I think it’s time.”
    I was given the gift of being with her at home when she breathed her last. But all that would not have happened if our whole family had not already been vocal and communicated our end-of-life wishes.
    In closing I’d like to quote a Jesuit nurse. He will do all he can to help others. But, “If God wants you dead, I can’t stop that.” Peace, joy, love, and laughter to very end.

  18. Eric Miles says:

    My grandfather recently passed at the ripe old age of 93. Over the past decade he had survived several major surgeries that almost claimed his life, including bovine heart valve replacement (3 total surgeries for that one, after a wound site infection) and for colon cancer. With each major medical procedure, he was definitely granted a few more years of active life, including the chance to meet my daughter, his great-grand daughter.

    But this last round, he got sick and once the feeding tube went in… he was pretty much over it. After the tube came out, he wanted three things: family, chocolate and morphine. He died liked he lived, happy.

  19. loren says:

    you don’t know how many times I have stated starting before certain procedures e.g feeding tubes -”don’t ever let anyone do this to me!” Live life to the fullest, take care of your after life concerns, i.e., hope in the resurrection, etc., and then die. there are much worse things. A near death illness made this very real to me. LH

  20. Henry Baggins says:

    I love see the “all knowledgable” RN’s on here spouting off about the lack of proper informed consent and care provided by MD’s.

    As always, you can count on a nurse to complain, bitch, whine, and tell everyone how wrong the doctors are/how right the RN’s are…..until something on the floor/ward/ICU/ER/OR actually happens….then “its not my fault, im just a nurse!”


    • Edward Parker, Jr., MD says:

      My stepmother died with inadequate pain relief during her last week of life in a state where I was not licensed to practice medicine. I had to speak firmly with the hospice staff to get my mother’s doctor to increase her pain med. We even hired someone to push the button every 15 minutes on her drug-delivery machine during the night while we tried to get some sleep. This gave my mother extra pain medicine. When she woke up about 10:00 AM, she felt better and with less pain than she had had in two weeks.

      My advice is to stay out of Catholic hospitals if at all possible if you are dying. The nurses and Catholic doctors will look over you like a hawk to make sure you don’t give more than the usual amount of pain medicine. Not all RNs or MDs in Catholic hospitals will try to take your license, but some are religious freaks who think they are doing God’s work by making you suffer during your last days.

      Second, be very aware of oncologists and radiation therapists. Some of these folks are charlatans who will treat you right up to your last day of life, provided you still have insurance or personal coverage.

      Third, every patient needs an advocate (ombudsman) whenever they are in a hospital.

      Fourth, out of sight and hearing of ICU nurses patients may make their wishes known to their doctor that they want everything possible done to save their lives. Families sometimes ask this as well. (I know this has been covered already.) Doctors don’t always think it is reasonable to do horrendous surgery or chemo/radiation Rx. Maybe under Obamacare they will be told they are not allowed to do ANYTHING once you reach a certain age. This worries me as I am 73 and in good health. Will I be deprived of any therapeutic Rx in the future?

    • John says:

      Agreed. I almost had a bunch of nurses kill me following surgery. I kept telling them to ask the doctor to switch me from dilaudid to morphine for pain maintenance following surgery because I was reacting badly to the dilaudid.
      They decided in their infinite wisdom that they knew better, and didnt forward my request to the doctor. Because they thought the morphine would be more habit forming.
      It wasnt until they almost went back in that my surgeon heard my request straight from me, and we both discovered the nurses and had simply ignored my request.
      I should have sued the nurses.

      • barbara says:

        Sad to hear your story. Not all RN’s act like that. Working many years in PACU, I considered myself to be the patients advocate. For pain issues, a quick call to the surgeon & anesthesiologist , suggest a Pain Consult, all with the goal of patient comfort. Changing from Morphine to Dilaudid was done within minutes, with MD guidance. I cannot decide which drug to administer without a doctors order, but yes, your doctor needs to be informed, that’s my job

      • Stef says:

        umm weird- i don’t believe i’ve ever hear of a story like this before.. and how long did it take you to talk to an MD??? bc they should have been rounding on you every day???

  21. Dylan says:

    Very interesting and insightful read.

    I feel like there’s another major factor overlooked by the article. People don’t want to die. I mean, most people REALLY don’t want to die (nor do they want their loved ones to die). I think people who work where they see death all of the time (like in the medical field) are far more likely to realize and come to terms with their mortality and realize death is an inevitability. I think that’s another factor at work here.

  22. Liz says:

    As a Peds nurse for many years . . . I have some to call the long-term, PAINFUL, futile treatment of infants and children as medical child abuse. If any other group of people (aka a cult) did half of what we do to torture these poor kids in the name of “healthcare” they would be reported to DHS and they would be jailed. Just because we can, doesn’t mean we should, and we can’t fix everything. I agree that the public has unrealistic expectations of healthcare, I also believe that the “I should have Died” reality TV shows feed into this, and we have raised a generation of people who have never heard the word “no”, got a participation trophy for sitting on the bench, and think they know more than the MD’s and nurses because they can “google”. ICU nurses are leaving hospitals in waves because you can only handle the stress of experimenting on patients so long before the unethical aspects of our current healthcare system burn you out. To understand how MD’s and RN’s helped with Nazi war experiments we have only to look at what goes on in our own ICU’s today . . . .

    • John says:

      Given that most doctors do nothing but google or poor through physician symptom checkers, then I think most patients are nearly as smart as their doctors. All GP’s and internists do anymore these days is write referrals to the specialists.

      • anon says:

        I’ve worked around physicians and am currently a medical student and of all the doctors I’ve shadowed, I’ve never seen one look at Google or a “symptom checker” a single time. The only time I see a physician open a book is to confirm a suspect diagnosis. It’s entirely possible that a physician such as you describe exists, but to say “most” is ridiculous, uninformed, and melodramatic.

      • doc says:

        John, first I was going to attempt to clarify what GPs actually do. But given your level of ignorance, I will not attempt it

      • Noah says:

        John, do you understand how much schooling, studying, sacrifice, and time that it takes to become a doctor? My wife is currently a SRNA, and it completely consumed her life.

        I would love to try and perform surgery on you only using my tablet and google search. Want to let me try?

  23. lauren says:

    Liz, Amen! Couldnt agree more. Death is no longer inevitable or acceptable. I admitted at 94yo woman for heart failure with severe aortic stenosis. Symptomatic for over a year. Average life exp from symptom onset is 2yrs. I explained the plan, get the fluid off, get her comfortable and on stable meds and get her as much time with the grandkids as poss. Re resus status, ‘bring me back’. I explained what ‘do everything’ meant should her heart stop or her breathing deteriorate incl rib cracking, ETT and tying her hands down if she went for the tube. I also mentioned the likelihood of any success being about nil given her heart and kidney disease as well as her age. She and her daughter looked at me like i was from the Fox News ‘death squad’. Like i was withholding the medical magic wand that makes fact irrelevant. Her daughter said no one could predict the outcome. So painful seeing this age group with trach, dialysis and PEG tube but it can be an uphill battle.

  24. John Ballard says:

    This post has to be among the most durable ever to appear at The Health Care Blog. I think it first appeared in 2011.
    For those who want to explore the subject further here are a few of links. This is a collection I put together at a blog now gone silent, but for the moment most of the links still work, including one to an event that Dr. Murray took part in last July.

  25. Sadie McFarlane says:

    Wonderful article. My dad spent several miserable years getting dialysis twice a week (they never did figure out WHY his kidneys failed) and one day died during dialysis – and just like the article said, they broke his ribs resuscitating him. He was SO MAD, because he had died so peacefully, and they revived him so roughly. Then he wrote out his directives. Then he actually asked mom and myself if we minded if he just stopped treatment and died – and was both surprised and relieved that we did not. He died – peacefully and in his sleep – two weeks later. My mom died the same way a few months after him. I felt that they were truly blessed! What a horrible waste of money and resources and lives and happiness, that we feel compelled to prolong life NO MATTER WHAT. And all of this certainly isn’t making American Health Care any cheaper. We need a major revision in our thinking on the subject – so this article is right on target!

  26. Mke says:

    It’s is a very personal thing and this article makes sweeping generalizations and assumptions. I am a medical professional and I spend my days with many health care colleagues. Each one would likely do a different thing in the same circumstances.
    I personally love my life and family and I would fight for every moment, kicking and screaming the whole way. I refuse to, as Shakespeare said, “go quietly into the night.” I will suck every moment out of this life and I will fight to spend as much time in it as I can, thanking the powers that be for giving it to me and blessing me with everything in it. I think that is the least I can do for the gift that has been given to me. I believe in fighting for what you want, taking the bad with the good and recognizing that without the bad, all that good would seem pretty mundane. Just my thoughts.

  27. Bing Shi says:

    I am an anesthesiologist and dealing with end of life daily. I feel so sorry for so many patients.. Great and truthful article and comments. One thing is wrong in US is the law system.

    • e says:

      In the US, many tests, procedure, images etc are ordered just so that a doctor can protect themselves in the future from getting sued in case the lawyer’s ask “well why didn’t you order this and so on”. This can easily lead to over-investigation and over-treatment of conditions that may be benign to begin in. Not to mention the drain it has on the healthcare system.

      In Canada, hardly any physician worries about getting sued on a daily bases. In fact, mistakes get made all the time, but most canadian pts do not even think about sueing as that is not culture of health care system in Canada. This ultimately leads to better rapport with patients and less unnecessary investigations and overall better guinine care.

  28. F Dankoff says:

    I am the director of a university tertiarry/quaternary care centre ER, we see the sickest of the sick in their pre transplant phase for kidney/liver/heart/s bone marrow stem cell/pacreatic transplants. We happen to also deal with most of the nasty cancers: brain, pancreatic/billiary, ovarian, etc …

    I can assure you, that my very own living will is extremely agressive, I have no desire to receive many of the treatments I watch daily. And to the first post above; when we are too frank about these matters, no matter how pleasant, conscientious, and diplomatic we are … we often lose our therapeutic alliance with families. We therefore allow families and patients to come to their own conclusion by presenting all the possibilities.

    I work in Canada … there is no financial benefit in over treating patients, and we do not practice lawsuit prevention medecine.

    Tattooed on my inner right bicep are the words: Cogita mori – Vivere disce.

  29. Kristian Strand says:

    As an ICU physician I agree with most of your article. However, you state that you have had hundreds of patients brought to you after receiving CPR and only one walked out of the hospital. Such nihilism is probably based on poor functioning of the chain of survival in your health system. If the patient arrives in the ED with spontanous circulation you should see survival rates with good neurological outcome above 25%. However, if a there is a large number of patients with non-cardiac origin, no bystander CPR, no access to 24-hour coronary intervention and therapeutic hypothermia the results may be dismal. Although there are extremely poor results in reviving patients with cardiac arrest in large parts of USA, lessons from other parts of the world learns us that optimal treament of cardiac arrest will lead to great benefits for a large number of the patients. I do however agree that CPR should be withheld in patients with debilitating disease.

  30. Kristian Murphy says:

    Take a look at

    “It’s OK to Die” is available there.

    If we did to our dogs and cats, what we do to our parents and grandparents, we would all be facing charges.

  31. John Ballard says:

    Quietly, ingeniously and, of course, cryptically, the beloved – and sometimes feared – crossword setter Araucaria has used one of his own puzzles to announce that he is dying of cancer.

    The Rev John Graham, who takes his pseudonym from the Latin for the monkey puzzle tree, told Guardian readers of his terminal illness in Friday’s paper.

    Above cryptic crossword No 25,842 sat a set of special instructions: “Araucaria,” it said, “has 18 down of the 19, which is being treated with 13 15″.

    Those who solved the puzzle found the answer to 18 was cancer, to 19 oesophagus, and to 13 15 palliative care. The solutions to some of the other clues were: Macmillan, nurse, stent, endoscopy, and sunset.

    Speaking from his home in Cambridgeshire, Araucaria said this particular puzzle had not taken him very long, adding that a crossword had seemed the most fitting way to make the announcement.

    “It seemed the natural thing to do somehow,” he said. “It just seemed right.”

    That said, he has no plans to refer to his illness in future puzzles: “I should think this is a one-off because I don’t really know what else there will be to say.”

    The 91-year-old said he was very pleased that his doctors had decided against surgery or chemotherapy – two prospects he had been dreading. Exactly how long he has left, however, remains something of a mystery. “There isn’t a prognosis, really,” he said. “They simply don’t know how long it’s going to take. I asked them last week how long I’d got, but nobody knows how long you’ve got! They said it won’t be years and years, but it could be a large number of months.”

  32. Caroline Carlson says:

    Many stories……. . My only comment is that this is not about the nurse, the grandmother, the father or the doctor etc. This article should focus on the community as a whole having a right to say no and being educated with the facts and figures.
    Life is precious and is about quality not quantity.

  33. Chris says:

    This is a nice well written article with lots of warm and fuzzy moments. However, this is no way to talk about medicine. Let’s stick to the science that’s so far given us better results than witch doctors and quacks. I’d like to consider my treatment options based on objective science – not a few anecdotes. If over-treatment is common then where is the evidence? Where is the data?

    • John Ballard says:

      If quacks or witch doctors are represented here I haven’t noticed. And if there were, beliefs are as important as science to the acceptance of death when science does not provide recovery.
      I hope you are not a doctor, Chris.

  34. Thank you so much for putting into words the pain and suffering I see every day. I work in a busy ICU and these situations are what makes my walk from the parking garage to the unit so unbearable. Our society needs education, and as angry as I sometimes get when the 98 year old with terminal metastatic lung CA gets tubed, I have to understand that the families often times really don’t know what they’re doing. We need more doctors who can paint the true picture before starting this crap.

    • Rod Williams says:

      We need death education, explain to people that there is a time to be a human mammal and a time to not be a human mammal. If I see another 400 lb + person in an electric wheelchair smoking a cigarette, I’ll barf. Shed the body dammit. Get rid of it. I was born in 1942 so I quality except I can still run and work my butt off.

  35. Ellen says:

    Great article. As an ICU nurse in a teaching hospital, I find that many of our physicians (mostly residents, but even some attendings) are extremely uncomfortable when it comes to discussing end of life issues with their patients. Often, we nurses have years more experience at the bedsides of the critically ill. It becomes our responsibility to advocate for our patients, to encourage the MDs to be honest with families and look at the “big picture”. Many of us feel as if we have to throw ourselves across our patients to prevent further invasive and futile interventions. Frequently, it is the nurse who finally convinces the MDs to stop the suffering. I’m not sure why this is. Are some doctors not being taught about the FACT that people die? Are they so myopic that they can they can only see as far as their next intervention? All I know is that, from my personal experience, nurses (and RT) are often the people that stand between the dying patient and endless, painful interventions.

  36. Teri RN says:

    I am a 30 year ICU nurse who is glad to see the change from saving everyone to talking about quality of life. I have seen the save the 90 year old way to much. As the newer doctors come out, the conversations are starting sooner. I personnally want to tattoo DNR on my chest! lol No seriously, it is a choice and no one will live forever. Just look at what we see everyday and realize that we all have a choice.

    • Rod Williams says:

      We need to upgrade using the information that we have learned, traditions tend to stick us in the mud, hamper our goal of making a better world for all inhabitants, not only human mammals but all life.

      If a person cannot care for themselves they should happily accept shedding their body, much like a caterpillar sheds its skin. We are evolving life though it seems that the human are the most destructive mammal on this spinning piece of space rock.

      Them to count how many orbits an object has .traveled around the sun so you know what age to act. Real stupid. Not very bright. Time was invented by a herd of fairly ignorant mammals for navigation then it went to when to pray and tithe then when to be at work. LOL We real smart mammals.

      Since humans are the most destructive, that would make us the more ignorant of the population. Just saying.

      When we discover that we really aren’t so important, nothing in the universe would want or needs worshiped by idiots or anything else. Imagine being worshiped by those of an equal intelligence or better being worshiped by more intelligent beings. Nope, won’t work gotta be worshiped by those who are far, far below you before it feels good. And if you do not like how one or more of them are behaving, zap them to eternal hell, just remember to give those who excelled high quality ear plugs, cuts out the weeping, wailing and gnashing of teeth. .

  37. Adam says:

    I wish I would have found this article when it was written–or even more, had information like this a couple of months before my mother’s cancer went terminal. She was an Registered Nurse that worked nursing home for the most of her career, and knew better, but just didn’t know how to communicate this information with the family. Being Southern and not one to be open with many things, this situation could have played out better. I lived over 2,000 miles away, so I missed even more about her progress–or lack thereof. She was given a month or two at most to live almost a month before I was told of her condition. I put my life on hold and really took a huge financial blow to come see her, and subsequently take care of her; filling in the gaps hospice left. She had an older sister that lived about three miles away, but turned out to be surprisingly useless, leaving me to bare it all.

    When things finally turned really ugly a few months, this article really would have helped. She, and the family, didn’t want her to suffer any greater than she had, but we kept getting pushed and mislead to think certain measures were to reduce suffering, but were probably contributing to her month-long decent into a ultimate “humane” suffering death. I was prepared to give her a lethal dose of morphine after a series of strokes left her unable to communicate, but I was worried about causing any increased suffering. I had been trained to kill in any ways possible in the military, but the slightest chance I could cause a more prolonged or pain death keep me from acting. I tried researching the information I needed, but I couldn’t find anyone of qualification that was willing to state definitive information. No one foresaw my mom going on for weeks in the state she was in, so the risk to step in never seemed to be worth it. When hospice over-rided my attempt to ration the best course of action after she lost the ability to eat, drink and take pain medication and made the call for me to move he into the hospital, I should have stepped in to end it for her. It turned out she suffered so much more at the hands of “experts”. I should have continued with suing the hospital and hospice for how they handled everything, but dealing the fallout of everything and the caos my life would be following her death, overshadowed the disciplinary actions that were needed (it wasn’t about money, but awareness for incompetents and being held accountable as professionals–any money gained would have been donated to cancer research). After weeks of not leaving her side for more than minutes, the day she died, I was going to take matters into my own hands. She finally died as I was digging out the left over liquid morphine she had from the final days at home.

    No suffering I’ve seen from war or life in general has come close to what I witnessed with my mother’s cancer. I thought my grandfather’s stroke driven death was awful; it looks now short and humane by comparison. Her death certificate said the cause of death was cancer, but I know it was dehydration and malnutrition. Only the worst of the worst humans deserve such a death. The supposed death of Jesus had nothing on this. I was an agnostic before this, but now I am a certain atheist. No person with compassion and the ability to prevent such suffer could allow it without ignoring what’s really happening or they are truly an awful person.

  38. john devis says:

    They save so many life,doctors are assets of societies.

  39. Laura says:

    This article, and the attached comments, resonate deeply with me. I am “just” a staff occupational therapist at a 48 bed dedicated short-term rehab center (not a nursing home /SNF). I began keeping a log of the number of deaths we had each year – it has been 20-25 per yr since we opened 3 yrs ago. The mortality rate is astonishingly high. Why? Because hospitals are discharging patients to “rehab” who should be on palliative care, giving the message to these pts (more accurately their families) that there is hope for full recovery. Most (perhaps all) of these patients arrive with a very poor understanding of their condition. A few families have chosen to withold from their loved one their diagnosis – even if the patient is competent – because they say this information will “depress them”. Most families I have encountered have indicated time and time again that no one has spoken to them about care options aside from going to rehab. They have no interest in hearing our rehab attending physicians discuss their condition, because these doctors are not their PCPs. I have had patients leave for appointments withe their ONCOLOGISTS and they come back saying ‘my doctos says I am doing great” when clearly they appear very close to death. Meanwhile, our rehab supervisor instructs the therapists to treat these patients for a few hours a day to maximize our facility’s reimbursement. The more minutes spent with them, the more money given to the facility by their insurance carrier (typically Medicare). I watch patients in their last days of life being dragged down the hall to “walk” or exercise. As a matter of personal principle, I refuse to add to their suffering and focus my treatment on positioning and comfort, helping them be clean and providing socialization and companionship. When a patient requests not to participate, i respect their wishes. My facility policy is that the therapist has to attempt treatment 3x before you can accept their refusal. And nearly every patient has 3 different therapists per day (PT OT Speech). My non-aggressive approach has not endeared myself to the facility administration. I cannot begin to tell you how many times I have been yelled at, condescended to, and harshly questioned by the families of these patients who feel that I am responsible for their family member not recovering. That their declining family member is a result of my not being a competent therapist. Meanwhile, I have been honored nearly every month by being elected a candidate for Employee of the Month – votes are from fellow staff members and patients/ families. I am an excellent therapist who cannot reconcile the cognitive dissonance of observing patients who could enjoy a peaceful end of life with the silence of a medical community who are unwilling to be honest with their patients and their families. Again, I have to emphasize that the expectations of these families are that if their parent/sister etc are sent to a REHAB than this equates to them that the MD/ hospital feels this is the most appropriate setting for their loved one. I agree with one of the comments which stated that hospice should be referred to as “comfort care” – a neutral term that everyone can understand. And ethics dictate that all patients (and their families) be given full disclosure and honest information by their medical providers. This does not just mean answering questions about end-of-life IF ASKED by their patients/families but to be upfront and provided as a matter of policy to each and every patient that comes through their door. The system as it stands now is flawed and each of us on the front line has observed this with heavy hearts.

    • A daughter says:

      Laura – thank you. My father did that horrible end of life dance: hospital stay, followed by 30 days (medicaid paid for) rehab, home for one week, back to the hospital, 30 days rehab (at a different facility), back to the hospital. We finally found a place designed to deal with elderly patients with dementia. He died a week later, but more comfortable, and with family nearby. The last three months of his life were some of the worst and I wish I’d done something differently. Very much appreciate the therapists he worked for which were generally lovely people, but hope I’m not doing rehab strength building exercises the week before my death.

  40. Terri says:

    I see this from two perspectives: as a pastor, who is often present in hospitals when families/patients are making critical decisions, and as the wife/caregiver of a man dying from a progressive, degenerative neurological disorder. Most times–MOST times–I’ve witnessed physicians convince family members to do whatever can be done to extend life. Unless a palliative care specialist is involved, I’ve seen 90+ year olds put through cancer surgery and chemo, G tubes, tracheostomies, and a host of other invasive, painful procedures. I was in a room where a nurse cried as she tried to draw blood from a man who screamed in agony as his seeping flesh tore loose–and this was after Hospice had been called and his daughter had been told his death would come in hours. Why did his doctor order a blood test? Doctors tell families/patients what “can” be done, often dispassionately, without talking about the quality of the life being extended. For fear of legal action or not wanting to admit the limits of his/her abilities, or other unfathomable reasons, I’ve rarely heard a doctor explain what these extreme measures mean.

    My husband’s condition is irreversible; the only “treatment” is controlling his symptoms to improve his quality of life, but I read Facebook posts about cutting the “waste” in Medicare, knowing they are talking about my husband–his care costs a fortune (I will probably lose my home after he dies). Well-meaning libertarians say it’s up to churches and charities to pay for those who can’t afford care: my entire yearly salary wouldn’t cover my husband’s medical costs. All the while I am told by his doctors that he needs physical therapy, speech therapy, occupational therapy. When I say, “we can’t afford those things,” the answer is “but he needs them.” Do you know how that makes me feel?

    I’m sorry, but I think most of the responsibility belongs to physicians. Life is finite. Be as brutally honest with your patients as the author of this piece. Don’t develop a hero or messianic complex (trust me, I know what it’s like when people expect you to always have the right answer–who think you’re something more than human). Explain what these choices mean. When my father was urged by his mother’s doctor to give permission to insert a feeding tube–when she was 99–and told, “if you don’t do this, your mother will starve,” I fought them both to let her go. My father still bears guilt over that decision.

    God bless Hospice and palliative care givers and physicians. I wish all physicians would learn from them.

  41. Mary Andersen says:

    Frankly I thought the article in it’s basic content and message is outstanding. I don’t really care about the particulars I care about dying with some dignity and letting nature and God take me back from whence I came. At the age of 57 and having had multiple heart surgery, back surgery, C-sections in order to have children and living every single night and day in pain, well I am ready to go because for me my body is only a vehicle. The true essence of who I am lives forever so death is not an end but a different beginning. Let me go from one to the other with class and celebration. My family knows and the papers I carry with me at all times say DNR. I will not stay one minute less nor one minute more than what has been written in the “plan”, so I dare say that anything to the contrary will make much difference. Death is a transition and not to be feared. What is frightening is what people do to keep you from it! Including family.
    I am ready for the next adventure!

  42. irene says:

    I’ve read a lot of articles like this. The thing they all have in common is that the writer will give a scary list of worst case scenarios. Rarely do we hear about the patient who gets care (excessive or not) and who lives and has a reasonable life afterward (by their own definition, not healthcare staff members’). I signed a DNR for my mother 4 1/2 years ago–at the urging of doctors–and she survived and is still alive today.

    She became conscious again and when I asked her what she wanted, she said she wanted to live. That’s when MY nightmare began. I was confronted by medical professionals with the attitude of the writer above. Getting my mother any care became almost impossible because everything was seen as “excessive”.

    I resent the characterization of the families in this article. Not all of us are hysterical and unprepared. Most of us are reasonable, if a little surprised by events. That does not mean we are incapable of making choices. The problem is that we rarely get to make “informed” choices because the doctors, like this writer, make decisions for us by not sharing all the information. It’s patronizing and distressing. These people are not equipped to play God — they seem to see people as products on an assembly line. I’ve written about my experience here:

    • Mary says:

      I am so sorry that this has been your experience. I must say that as an RN in acute care I have watched (at least from the hospital staff, MD’s & DCP’s) honor the families wishes. I am proud to say that we understand that we never know what cultural idiosyncrasies might resides within a family. I’m glad to know you were strong enough to stick to your guns. I’m sorry for those who don’t know how to navigate this system when they don’t receive proper support.

      • Mary says:

        I hit submit too fast. I am proud to say that we understand that we never know what cultural idiosyncrasies might resides within a family and we defer that the family and honor their wishes.

  43. Mary says:

    I agree with the basis of this article. In that with a cancer that is advanced with no hope of remission and that only painful treatments would gain very little time. I understand that a physician in the know would opt out of treatment. I also relate to the fear of patients and their families as I have witnessed. Of their going much to far to sustain life, in their ignorance of having past the point of no return and the suffering of their loved one. They seem to not hear the doctor or nurse telling them that its time to let their loved one go.

    I do however take exception to what I consider dangerous “advise” , perpetuating bystanders to do even less when you discuss CPR. You refer to a man who walked out of the ED after receiving CPR inappropriately. What harm was done? Yes, it was in appropriate. It did not threaten his life. Broken ribs heal. Encourage people to administer CPR. Teach a course in proper CPR. Fix the system. Don’t tell people to stop please.

    I also take exception to the implication that MD’s or other practitioner’s would tattoo a NO CODE on themselves as if they would have no CPR under ANY circumstances. This would be an incredibly drastic measure. A healthy individual would not take this action.

    I feel as if you are seeing things from a tiny hole in your ED and not getting any perspective from outside of it. Please have a look around and consider your actions when you write such detrimental words. Honestly, I appreciated the way your article began. I wish you had stuck to your original point to educate others on the length we go to keep people alive (sometimes too long) in our medical system.

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  45. Diane Olberg says:

    Such a wonderful article. Thank you.

  46. Leigh RN says:

    I work as an RN in an extended care facility, which is rapidly changing to a complex care facility. We are finding that more and more, rather than admitting people with dementia that can no longer cope at home, we are getting very frail elderly with complex medical histories who have been hospitalized and treated multiple times. More and more of these frail elderly are being admitted as full codes, with requests to transfer to acute care or ICU as required. Many of these admissions and their family members have no idea what they are signing up for when they request to be a full code and that prolonging life is not the same as improving quality of life. It seems to me that a lot of family members think that in order to show their love, they need to request all measures necessary to prevent death. I think that all health care professionals need a bit of a tune-up in how we approach these kinds of conversations with the seriously ill and their loved ones. Sometimes it seems that they need “permission” from us to stop treatment…like they are somehow disappointing themselves and their loved ones by not agreeing to all necessary treatment. It is a conundrum, for sure, but I feel that I see a lot of unnecessary suffering every day in my work-place as a result of this desire to show love and devotion through invasive and sometimes futile procedures. It seems as though no one is allowed to die of old age or ill health any more, but rather only through treatment failure.

  47. Lance says:

    I do not favor the quitting attitude promoted in this article.
    There are numerous examples of people surviving against all odds.
    One of them even won Tour de France 7 times.

    For sure i respect the “last will” of the convalescent, but medical care
    is scary enough and the underlying message here risk leading
    to people avoiding medical attention for curable conditions.

    An MD Discouraging people from CPR is highly questionable.
    There are numerous people recovering from cardiac arrest.
    Also cracking ribs during CPR is not an objective it is just something
    that is acceptable during the condition and definitely the least
    of concern to the receiver. This assumes CPR is motivated as every one
    trained knows that forceful chest compression can casue cardiac arrest.

  48. Rod Williams says:

    There is need for an understanding made in this country/world that when an individual is past prime with prognosis being the same, that doctors and staff must not be held responsible for patients condition even if the patient goes into a complete physical mammal body shutdown. That this is normal as well as necessary and if they wish the doctors to do what they can to make the patient comfortable they should sign a ‘no sue’ agreement.

    Otherwise if the designated caregiver would like to take care of the patient on their own, let them do it. Once over prime it’s time to think about the next logical step of life whatever that may be. Humans must be made aware that losing ones mammal body is in fact normal as well as necessary.

    It’s unfortunate that our species are not yet intelligent enough to understand about life. Maybe in another 100 or so orbits we hopefully will be but do not hold your breath, after all we are dealing with mostly ignorant mammals.

    For me personally, from my life’s experiences, being a mammal sucks. Childhood was interesting though.

  49. It’s sad that more doctors don’t know about the subversion of the medical profession by the petrochemical industry and Big Pharma.

    Too many doctors are oblivious to the fact that chemo and radiation are cancer causing and very ineffective for curing cancer.

    But there are cures for cancer that have been outlawed by the selfish and the clueless.

    I did a study last year on the geographical spread of cancer. The results were startling. It showed that cancer, by and large, is a manufactured disease. Those countries that are Westernized have the highest prevalence of cancer. The rich nations that don’t have high rates of cancer are not aligned with the West. They don’t use sunblock on their skin. Petrochemicals cooking in the ultraviolet, creating a carcinogenic stew.

    Look at motive. What is the motive of Big Pharma? Profits! They have a fiduciary duty to go after only profits. Cures are anathema.

    When will more doctors get past their egos, wake up to the fact that the mind and nature do far more to heal than petrochemical pharmaceuticals or surgery?

    When will more doctors wake up to the fact that their education has been guided by the selfish machine of corporate greed, starting with the Rockefellers and their grants to medical schools a century ago. And in what industry did the Rockefellers make their fortunes? Big oil. Their philanthropy was like that of the Pharisees, covering the scab of greed and lust for power.

    If you desire to honor your Hippocratic Oath, you will investigate the darker side of medicine and not listen to the lies of the selfish machine that makes up the modern medical establishment. If you’re in it only for the money and ego, then simply ignore this and let your patients die needlessly.

  50. Brittany Coppola says:

    I have a problem with the commentary that doctors and pharma are just out to make money. My father is an ENT and the man works at least 60 hours a week, and he’s pushing 60. He constantly gets letters from his patients, thanking him for saving their lives or helping them feel better. I’ll never forget when he read one of them to me and teared up. I think I’ve seen him cry 4 times in my entire life. He ALWAYS goes the extra mile, and there are several times when some of his patients can’t afford it and he lets it go. My mother works for Glaxo, and she too is an incredibly hard worker. She works putting on education programs for dentists and has done an amazing job making connections within our community and getting the word out about oral health, something most people don’t know anything about (did you know that there’s a link between not flossing and cardiovascular disease? I didn’t)

    With regard to the commentary about saving costs/better quality of life by not drugging people up/extending their lives in drastic measures, put yourselves in the doctors shoes who DO prescribe such measures: the average lay person doesn’t remember much about science since he/she had to take bio 101 their freshman year of high school. That being said, it’s hard for doctors to put themselves in the shoes of the patients, BUT, if you can, think about it: how would you like it if a doctor, someone who represents intelligence and holds the keys to your loved ones health, flat out said, in so many words, that it would be stupid/futile to try and save your family member? The last thing ANYONE wants to hear is that the fight is up, especially when they lack the science and know-how that doctors have spent their lives studying. Thus, I choose to believe (or at least, I want to believe) that doctors are coming from a place of empathy, not greed for more money, when they prescribe drastic measures to save a seriously ill patient, even when they know in their hearts it won’t make much of a difference. It might not make sense economically, but what’s worse, spending more money or completely killing someone’s hope and will to live? Money is money, it’s paper bills that people put intrinsic value in, and there’s plenty more where it came from. I think we’ve all read incredible stories about the power of the human psyche when coupled with a strong desire to live. Without that light, that fire inside us that keeps us going, we are nothing, in which case death might knock on our door too early.

    My Uncle Tim passed away a little over a year ago from a very aggressive cancer. He was 38 and left behind a wife and my two young cousins, ages 8 and 12. He only lived for 4 more months after the diagnosis, but if he had just decided to quit taking the medicines/chemo, he might have only had 2 more months. Tim wanted to live, for his kids and his family, but he knew that giving up medications right away would decrease his chances even more. So he kept with the drugs, and for a while it abated. It eventually did get to the point where he became to ill to endure chemo, but the point is that his life probably was prolonged. We can’t go back in time and predict how MUCH longer it prolonged his life, but that question is pointless: whether taking the drugs prolonged his life by 2 minutes or 2 months is irrelevant. Ask his kids. 2 minutes is 2 minutes more with their dad. And that just doesn’t have a price.

    There’s a lot I’d like to say in this post, but for what it’s worth, I guess the main message is to all the naysayers and doctors haters out there, please know that there are good doctors who do exist. The reason you can’t see them is because they’re working hard, and they’re not giving themselves a pat on the back, or giving commencement speeches, or attending fancy conferences and donning $1,000 suits. They’re in the midst of your communities; you’ve just got to find them, they exist. I promise. To all the doctors out there who are jaded by the conversations regarding death, who think they know what it’s like and have already started mentally preparing for how to handle their own deaths: don’t assume that the way you handle death should be how other people should handle it. We all make our own exit out of this world on our own terms, and no one has the right to make a judgement call about the “best” way to deal with it, even if it doesn’t make sense or isn’t economical. Death is an intimate and inevitable part of this life on Earth, and just because your way of going out doesn’t match mine, or your parents, or your neighbor, doesn’t make it worse or wrong or better or not. Thanks.

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