Medical Practice

How Doctors Die

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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446 replies »

  1. Hi Dr. Murray, I’m a few years behind but super grateful to stumble across this article under current self negotiation around DNR and general life planning. You give a great insight from the other side of the table which most don’t get the pleasure to hear. The last thing I would ever want to be is a burden on my family and the system so I sincerely appreciate your shared story.

    We need to make the best choices we can in regards to our health as early as possible and commit to making the most from the finite time we have.

    Thanks.

  2. Both of my parents were medical doctors. They made sure we all knew they wanted DNR. They put a sign up on the inside of their door stating this so no one would question their wishes. They died lingering deaths but not do to any medical intervention. They did not shun medical help or doctors. They also did not seek to prolong their lives. They felt they had lived a good long life and when it was their time, set by God, they went. To them death was neither something to fear or avoid nor something to seek out. It was just everyone’s future that would arrive when it was time.

  3. I got goosebumps while reading this post, no one wants to die and when it comes to Doctors it’s really painful, they know their disease and they know what pains they’re going to have and think their death is more horrible than a normal guy’s death. Because the fear of death can kill them before death.

    Ewan Sims
    CEO of https://www.massagetut.com/

  4. We really need Dr. Kevorkian, many like him actually and it’s a shame that since what we mammals call death is natural as well as necessary, too bad we are not yet intelligent enough to accept and make it a fun positive occasion.
    The human herd of mammals overall are the most destructive on the planet which makes us the most ignorant. We are born into a dimension that is insane and live our lives. War is the most insane act that a human mammal can do, all humans on the planet, past, present and future are blood related and war is the prime way to solve our problems.

    A part of the problem is that we believe that we are intelligent and have dominion over all life yet, our book say that we are and we have been programmed to believe the printed word.

    The highest goal I see for any species of life who live on a piece of spinning space rock is to give our children a good place to be born. In order to do that all war would have to end worldwide. Unfortunate that our parents were not more intelligent. Sad really.

    I went into physical shock from pain in 1988 from an abscess, had a tooth ache one Friday night after arriving home from work, decided to wait until Monday morning as dental prices would be less. By Saturday night I was in much pain so I smoked female cannabis to help me control the pain. I again woke up early Sunday morning and the pain was really bad. I became hot and turned a fan on my and lay down in bed and very soon I became cold, very cold and it was all I could do to pull covers over me and place a pillow under my feet in order to get more blood to my head.

    The next thing I remember is feeling wonderful and a floating sensation, neither was it dark or light, there was no pain. Felt like my feet were shutting down and working its way to my brain. I didn’t mind, I had accepted shedding my flesh in 1977 after running from the thought of death in May of 1969, ingested some San Francisco LSD while living in New Orleans, On that trip Death came to me and said that it was time for me to go, I was laying in the back of my VW van in the New Orleans French Quarter and here Death wanting to take me, My thoughts were, there must be some error, others die, I don’t. LOL

    I ran, I drove from there to Phoenix spending 1 night at a rest area in Texas, the next night I was back in Phoenix. Death still followed me especially after dilating my blood vessels with female cannabis bud so I slacked off on that for almost 7 years then had enough carrying this fear of no longer being a mammal so I smoked a bowl of pot throwing caution to the wind and realizing that Death will come for me again and when it did, I with every atom in my being accepted it and I had an emotional climax that was so wonderful and lasts to this day.

    Then in the summer of 04 I woke up preparing to do some chores on that Saturday morning and I did not feel quite right, my head felt swirly and I was tired even though I had just awoken, Strange I thought, something is happening to me that has never happened before, wonder what it could be I thought? My wife was trying to get me to go to a hospital as she knew that something was up as I did not look very well to her, I assured her that all I need was sleep and I’d be fine. At that point in my life I had orbited our sun 62 times, was born in 1942 and mom had a brain aneurysm a decade earlier and died, The thought of death while this was happening didn’t bother me at all. No concern. Her and a son in law who lived across the street took me to a hospital and they examined me, placed me in an ambulance with lights and sirens and took me to Barrow Neurological about 5 miles away, I remember none of this, I misplaced 6 weeks of memory from my life due to the aneurysm in the basilar region of my brain. I had one of the top brain surgeons in the world treat me, clipped my bleeder with a tool that he invented, Dr. Robert Spetzler. I heard later that he had stopped in to his work to say goodbye as he was leaving for a vacation. Sorry but thanks for the clip.

    At 6 weeks and 99 lbs, down from 131 the hospital advised my wife to place me in a suitable home as I had no memory yet I was awake and was told by friends that I seemed like I was only partially there from those who had visited. That same night in a pitch black ward of moaning people my memory made a connection and I knew who I was, where I was and why I was there. My problem I had to pee really bad and was locked down in a nylon webbed bed and could not get out. I buzzed, yelled and screamed a few times to attract anyone who could help me but there were no takers.

    I wadded up a top sheet tightly and stuffed it in the bottom corner of the bed and used it to pee on then went to sleep which was easy. Next morning a staff noticed I had remembered something so they kept me another week, gave me an appointment for 3 years down the road and sent me home with a bottle of Dilantin. Dilantin side effects are not very pleasant and are in fact dangerous but they do dilate blood vessels.

    On the other hand a University study during that period showed that cannabis also dilates our vessels and makes a good stroke preventer, much better than the chemical capsules and without any dangerous or unpleasant side effects. The very first thing I remember anyone saying to me once my memory made a connection was that I needed to eat solid food or I would be put back on the feeding tube. As 1 of Dilantin’s side effects it takes away the users senses of taste and smell so my food didn’t have a taste or smell, all I could discern was how warm it was. Had they given me cannabis I would probably have eaten the cafeteria out then asked for more.

    I cancelled my 3 year appointment, didn’t have the 1000 dollars to have dye injected into a vein then scanned. While awaiting surgery the staff wanted my medical history, we’ve had the same family doctor, a really good physician and surgeon for over 35 years and my history went back 35 years for a hemorrhoid which the good doctor explained to me how I could eliminate it on my own. That was it, colds and other sicknesses were rare with me but then I feel that my eating habits had the most benefit to my overall health which was eating my first meal of the day after working my ass off on my job. I ate good and lived off stored enzymes as do the large jungle cats and such though they average 2 meals per week and can go several weeks and still have that burst of speed to catch a meal.

    When the cat has had 2 meals, we humans according to our program what we have been taught have had 22 meals plus snacks. I ate my first meal of the day in the evening not becoming hungry once I became accustomed to my stomach sending aches and pains to my brain and then no hunger at all. I did this for over 30 years and when I have a lot of chores or work to do I can easily do it again. I can maintain a very positive energy flow and keep working without breaks while those who are food addicts go bananas and start shoving things into their mouth. This happened to me by accident, that a good friend had a triple bypass and I took his business over as well as my own for 17 weeks and I just didn’t have time to eat. Took a week, I forget how long but the hunger pains went away and I felt like a superman and never really became sick,

    Food is a killer. That’s my .02¢. Being a mammal is temporary, be glad, be very glad,

  5. Two years and over four hundred comments later Dr. Murray’s article continues to affect many people. Very impressive.
    And yes, Julie Andre, you’re right.
    ** Follow up by getting the proper advance directive forms for your state, get them properly filled out and witnessed.
    ** Decide at least three agents to be appointed to make medical decisions on your behalf in the event you are unable to communicate.
    ** Make sure they know who they are and have agreed to the responsibility.
    Put your advance directives where they can be easily found if needed. A file copy with your PCP is a good idea.
    ** Follow up every three to five years to be sure your agents are still available and have not changed their minds. Take that opportunity to read over what you said in light of medical changes that may have happened since you last checked — in case you change your mind about anything.
    ** I have heard that in some places the same individual is not allowed to be an agent for medical decisions and also have POA for the estate or other matters. I’m not a lawyer but that is a detail to check into.
    **And finally — pass the word…

  6. I just read this article in the July issue of Readers Digest. I can not tell you how it affected me. I am 63, in relatively good health and I agree 100% with Dr. Murrays attitude.I witnessed my beautiful Aunt, who had an aneurysm hooked up to life support where she stayed for months. This once 95 lb woman ballooned to almost 250 lbs during this time. Her family fought very hard to get her taken off, but, once on, hard to get off. I want to die EXACTLY as outlined in Dr. Murray’s article. I have told everyone in my family, my good friends, everyone I can reach of my wishes. I do not want CPR, I do not want to wind up an invalid for the rest of my life. I’d like to die in peace in my own home and pass quietly to the after life

  7. I seriously doubt that anything in the universe has ever died, change is the constant and not total disappearance of the former.

    Human mammals do not want to give up their body, they want to continue being a mammal and some humans show great fear of no longer being so.

    Shedding our mammal body is natural, normal and necessary yet those who have been successfully brainwashed tend to fear something they have been taught to fear which is the word death. Yeah and a caterpillar dies too, right and don’t tear a Starfish in two and throw them back in the water.

    We humans reside in an infinite universe and that gives all life unlimited possibilities. Being a mammal forever sailing on a space rock around a star then counting the number of orbits we have made which gives the human their age so they know how to act is, well really mammal.

    We each are in the school of life and from it earn character and knowledge which contain the key to releasing our mammal body so that we can gravitate to a frequency more civil.

    Billions of human mammals have thus far shed their mammal body and not a single complaint. If we worry about losing our flesh then when we do, we will have done all that worrying for naught.

  8. That is really sad to hear all this. I agree that there doctors and doctors, hope it makes sense. The system to me personally seems a bit too old, needs a reform to make it more of 21st century. I hope this new wave of tech, measuring devices would increase more the transparency and communication between medical staff and I think this devices will also show which doctors should take a break, which can work more during the shifts. I lost one close person in healthcare industry, that was a nurse and worked a lot more then required.

  9. I’m not trying to discredit the idea that eating a plant-based diet is a good way to combat disease. Please don’t put words in my mouth. I was taking issue with Rjoette’s comment, which had nothing to do with what Carol was saying about her decision for more radical cancer surgery, and seemed to judge others for not following her diet. “Each of us must live according to our own values” just rubbed me the wrong way. It sounded sanctimonious and self-righteous.

    Eating a plant-based diet is a great thing to do, but like I said, the idea that it can stave off every disease or condition is ridiculous. I have a genetic heart condition, and no one’s telling me that if I eat a plant-based diet it will suddenly disappear. Of course diet is important in preventing diseases…that are triggered by bad eating.

    As for the Steve Jobs example, I just used it because he’s very recognizable. Apologies if it wasn’t the case.

  10. Steve Jobs was NOT a vegan prior to his cancer diagnosis…this “fact” keeps springing up Everytime someone wants to discredit the need to eat healthy to combat disease…and it simply is NOT true. Also, today in medicine we have steered away from diet as the main catalyst for health, this is evident by the blank stare I get from patients when I emphasize a healthy diet as priority one for EVERY disease. What’s naive is to think that diet does not play the biggest roll in preventing disease as is actually does. Cause a car’s engine really doesn’t run better or last longer with routine maintanence, quality fuel and oil…yea that idea is just ridiculous! Pfft!

  11. Dr Murray I wish to commend you on your strong and open stance concerning end of life care. I have been an ER nurse “nights” for over 18years and I cannot tell you how many times I felt that the extensive care families wanted us to perform were excessive and cruel. My father a 65year smoker recently died in his sleep “as he wished” of a probably Myocardial Infarction. He always insisted that I was to have final decisions if he should ever end up in the hospital. He wanted DNR but knew my Mom wouldn’t be able to let go. He said ” I want Sheila to have Power of Attorney because she is the only one who knows want I want” and “Will pull the Plug”. Luckily, my father died at home and I never had to confront the rest of my family across his hospital bed. I have seen families in the ER decide to let the pt go and one member decide that everything should be done because ” I am the one who knows what should be done”. Then the hospital staff ends up going against the pt’s wishes because of one lone family member who is projecting their feelings and wishes on their loved one. Ironically, they seem to think that they are doing them a good deed and we are the evil ones who have no concept of a pt’s wishes. These are the people that I always insist MUST stand in the room and watch us resuscitate their family member. It is always surprising how quickly they change their minds.

  12. Hey, I’m a student looking for a phycisian to give me some advice in the emegency room doctor field for one of my classes. If anybody could write me a letter and give me advice and guidance and what I will need, where I should step into to and what it is that I need to do right now. Thanks!

  13. This article changed my life and thinking in many ways. For years I have been agonizing about end of life choices. I knew that I did not want the kind of intrusive and painful care that had been provided for my 88 year old mother (as described in many incidents above), but I was very reluctant to complete an advanced directive. Reading this article has given me peace and acceptance of the kind of process of dying that I want. I immediately sat down and prepared my advanced directive. I shared it with my son, a physician, who understood it perfectly and supported it and will help me to carry it out. No extreme measures. No CPR. Peaceful dying at home with hospice. Thank you!

  14. My doctor of nearly 20 years died this month. He was one of those special people who don’t come along often in life, one of the best and brightest, both in terms of intellect and caring. Patients do mourn alone. I felt bereft and thought I was crazy until I found some of his other patients to talk to. (He was famous worldwide in his specialties, so we connected via online obit websites.) It’s helpful to have that connection. We’re planning to work together to start a memorial in his name. From what I hear, it was also helpful to his family to hear our thoughts and receive our condolences (again through the online obit website.)

  15. Lynn thanks for sharing your story, I’m sorry for what you had to go through. Your mom is in a better place now.

    ‘Life is pleasant. Death is peaceful. It’s the transition that’s
    troublesome.’ – Isaac Asimov

  16. I really like your comments Rod Williams. It’s how I see things too. Humans are vile creatures, except when they are kind. We should be kind more often.

  17. You say you detect cognitive distortions in the article; I detect a lack of compassion and lack of clear communication in your response to it. You seem intent on attacking the author in vague and nonspecific ways, rather than addressing specific elements of his article you disagree with and making counterpoints.

    I agree that his article could have been clearer in some respects. His statements about CPR, for example, appear to confuse the (often good) results when CPR is performed on otherwise healthy, robust, young patients, with the (usually bad) results of CPR performed on frail elderly patients whose bodies will only be further damaged by it. Inserting a sentence or two remedially could clarify and strengthen the article in this respect.

    Re: your doctor friends who died of cancer while fighting the disease, the decision to “go down fighting” was clearly their choice. The author’s point is that some people choose *not* to fight when the consequence of “fighting” is horrific pain and disfigurement. They put in requests to be allowed to die without CPR, but receive CPR anyway.

    I’m glad the wishes of your doctor friends (to fight to prolong their lives) were respected. I would like to see the wishes of people who express the desire not to be revived, treated with the same respect. If you disagree, no doubt you’ll find “cognitive distortions” in my own thinking. Cest la vie.

  18. Carol…after my very first breast examination, I was called back (Darn! I just knew it, I said). I turned to my husband and asked him what should I do it I had cancer. He simply stated, “Cut it off.” I thought, “Thank you, the decision is made.” Fortunately, it was not cancer, but I now know what to do should it ever happen. To further prove my and your point of view, while working in a school years ago, an announcement was made that a former teacher at the school had died after a 10 year brave fight with breast cancer. I asked one of the teachers about this. She revealed to me that she had had two mastectomies when she had her first diagnosis because she had no intention of going through what this former colleague had go through. She was cancer free and now had two small perky reconstructed breasts. More important she wasn’t “fighting” for her life, but enjoying it.

    A little side note, when I returned to the doctor. The nurse looked so terrified for me and the doctor so concerned. I felt myself comforting them and reassuring them I was fine – partly because I hadn’t really absorbed what the possibilities were (I had calcification and was scheduled for a biospy) and partly because I knew what I would want to have done – have my beasts removed.

  19. Drew, loved your comment. How I wish we had done so with my brother who died of colon cancer that had spread to his liver and beyond. By the time he went to the doctor (We believe he had to have known long before, how could he not with a peach-sized tumor blocking his colon, yellow eyes and weight-loss?), he was given 3 months to live. He lasted 4. He tried chemo. My brother is still angry with the medical staff that would even success it, accusing them of going for the money (until he lost his insurance when his job fired him for being sick). He would have been much better off having palliative care and doing whatever he wanted instead of suffering swollen legs, no appetite, and sensitivity to cold. When the time finally came, he was taken to the hospital. He looked so clean and peaceful, sleeping before passing away. In the very, very end he didn’t suffer.

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  21. As a combat medic, your cases were young people with few or no comorbid conditions. Wait until you hear 7 or 8 ribs breaking in an 80-year-old woman during CPR, and then speak.

  22. I’m a doctor that has worked in ICU and the only way I would want resuscitation is if I was in hospital for removal of a hangnail and I had a witnessed/monitored cardiac arrhythmia. I have directed my family to sue blind anyone that resuscitates me if I have a terminal condition, including frail old age.

  23. Good article. My mother was a nurses aid and part time employee at nursing homes. When she was ready to make out her living will and papers I was my mother’s choice for DPOA and I’m sure she chose me among us five siblings for a good reason. Although my brothers were all in agreement with Mom’s wishes, my older sister and her daughters were constantly harassing me, the nurses, and hospital to get her more care and services during my mother’s last months. All staff were given every detail my mother wanted in writing and they stuck to the last wishes/hospice agreement. I don’t regret my actions.

  24. I am one of those health care workers who have seen some of the extensive care on people that might not have chosen “heroic measures” and do not want that for myself. That is, in the instance that I cannot choose for myself. I am also one of those who might choose human euthanasia for myself if I felt comfortable with how it is carried out. I have an advanced directive for my sister to follow but if I have to rely on someone other than my sister I would want to feel confident that my health care provider could execute my wishes accurately. At this point in time (I’m 57 years old), I’m not sure my usual PCP would/could carry out my wishes. I know it is my responsibility to make sure my family (other than my sister) know my wishes. However, there are always loopholes or extenuating circumstances. It is difficult to teach family members the extent to which you would consider what is “quality life” and what is not. If they have medical training it is o.k. but if not, how do you get that across?

  25. I am one of those health care workers who have seen some of the extensive care on people that might not have chosen “heroic measures” and do not want that for myself. That is, in the instance that I cannot choose for myself. I am also one of those who might choose human euthanasia for myself if I felt comfortable with how it is carried out. I have an advanced directive for my sister to follow but if I have to rely on someone other than my sister I would want to feel confident that my health care provider could execute my wishes accuately. At this point in time (I’m 57 years old), I’m not sure my usual PCP would/could carry out my wishes. I know it is my responsibility to make sure my family (other than my sister) know my wishes. However, there are always loopholes or extenuating circumstances. It is difficult to teach family members the extent to which you would consider what is “quality life” and what is not. If they have medical training it is o.k. but if not, how do you get that across?

  26. Linda: He might like to check out Gary Null, Dr Mercola and Dr Joel Furman for more suggestions on how to beat that cancer….

  27. I have a similar story regarding my grandad although thankfully we made the right choice and gave dignity and quality of life in his final months instead of subjecting him to all sorts of treatments.

    I often think that families of terminally ill patients who only have a few months/weeks left to live try to give them the best treatment possible for what they think is the right reasons but is actually the wrong reasons. Most of the time they are merely afraid of their loved one dying and keeping them alive at the expense of dignity is a selfish desire, albeit with the best intentions in mind.

  28. To my boyfriend Scott, Quality of Life is everything. The first time he had cancer he did 9 months of chemo. Three years later he was told he has inoperable stomach cancer stage IV with 2-4 months to live. He decided he wanted to live that time in beautiful exotic India and so here we are 11 months later…..he has accomplished his dream and created some amazing art andthru our blog shed some light on going with dignity. Read our story at Going To Goa Blog ….

  29. I disagree that the drugs and other pain relief available for palliative care at home are adequate. Morphine is primitive! If dying people could vote, they’d insist on some mood-alleviating substances in liquid form (no pill swallowing). Why can’t oxycontin be a smoothy? Why can’t people with bone cancer take heroin and/or marijuana with a bit of Lyrica? I am not drug-experienced but I have seen someone die with only the help of morphine, and I thought it was cruel and unnecessary. How dare lawmakers insure that patients and families will be helpless to relieve suffering? This is immoral.

  30. I plan to use this article – and its profound thinking – as a conversation-starter. I’ll start with myself, and get my own thinking clear and well-defined. Then I’ll move on to my spouse and my 91-year old aging parent. Ken, you have done a remarkable job in inspiring people to use our brains and clarify an important life-issue. Thank you.

  31. So if I eat a plant-based diet but still get sick, or have a genetically-based illness, is it because I’m a bad person without enough willpower? I’m all for eating healthy foods, but the idea that they will protect you from every disease or condition out there is hopelessly naive. Steve Jobs was a committed vegan but that didn’t stop him from dying of cancer.

  32. An orthopedist who developed an operation for pancreatic cancer? Amazing!

    However, on the How Docs Die bit – that is all so true.

    As a critical care doc for over 40 years (still going strong, thanks) I know that I do not want my family to sign off on me if I have an acutely awful condition which has a reasonable (say 10-20%) chance of being treated and of my being back on my feet, likewise, no way in hell would I want to be kept alive if the only destination was a nursing home or the grave.

    Chemo/Rad/Surg for cancer: Only for those which have a good prognosis if treated.

    Of course, like most Americans, I have not actually written any of this down – which having read this article will finally get me to do.

    In part I blame the unrealistic expectations raised by TV and movies, and the generally low level of education in the USA.

  33. Both my doctor friends died of cancer. Both did everything possible to fight it, full of life the entire time. It’s not the event that controls our emotions, it’s how we choose to look at it. The fellow who wrote this seems depressed, there are several cognitive distortions (http://psychcentral.com/lib/15-common-cognitive-distortions/0002153) in his writing.
    I personally know 3 people who have recovered from CPR, living just fine thanks.
    What is the difference between acceptance and giving up?

  34. Nicely stated Drew especially the last sentence, LOL.. We are an ignorant herd of mammals who reside on a spinning, sailing piece of space debris that;’s orbiting a huge ball of fire then to show our ignorance even more we count how many times we have orbited the fireball so that, believe it or not, we do it so we will know what age to act as in, ‘act your age.”

    There is intelligence in the universe, I call them the elders and the very first byte of lucid memory ever gets title of god. She is the eldest of all elders and all are an equal part of Her, Okay, god is 99 percent female, ,05 percent male.

    Had our parents been more intelligent we would have a more intelligent commune/world. Then again if all were really nice being a mammal on a planet and we went from birth as a human to when we shed (or shitcan) our mammal carcass. This is something that all should consider who definitely pass physical prime. Help to create a more youthful world, all old farts get the hell out, you’ve served your time.

    Being a human mammal isn’t the worst think we could be and it’s only a temporary gig, not even an nanosecond in eternity, With Eternity in the equation of life, nothing is impossible. I have worked out what I want to do. Since we are living beings with an attached memory pod, we are energy. Energy does not die, nothing in the universe has ever dies, it’s only changed,

    Toy with this; If every life form in the universe had every bit of its memory backed up and still being backed up, the amount of space in a Universe needed would be, just what concept the Arabs gave us, Zero.

    Easily probable using binary.

    Some while in the future now we’ll laugh about having been a mammal on a warring, greedy, dead flesh tearing world. We are also taught to keep your mammal suit for as long as possible as we don’t know what happens. If the people have been taught religion we are taught in addition to not dying but okay to kill if they worshit a different god than you, quite proper, kids too, hell a kid can fire a gun. We are sick ,,,,, <3

    Is there a way to edit after I hit save? Need some rest, born in the summer of 1942 and a workaholic who is tired. Not only that but based in Phoenix and I don't use a/c. If clarification is needed on any point, ask, I will have 3 letters after my name in the not so distant future, R.I.P.

    P.S. I am the victim of a kick ass aneurysm in the basilar region of my brain in the summer of 2004, Dr. Robert Spetzler did the work using a nonferroumagnetic Titanium Aneurysm Clip. After 6 weeks and down to 99lbs from 131 the hospital advised my wife to find a suitable home for me as I had no apparent memory, I did not recognize wife or children.

    That very night, pitch black and locked in a zippered nylon netting that would hold a wild beast my memory made a connection and I had to pee really bad. No on would answer my yells or screams, lol. So I wadded the top sheet into the corner of the bed and peed on it then went back to sleep. I was kept another week and discharged. I was not afraid through the process, I faced what most humans call death and eventually happily accepted it, even look forward to that shift.

  35. Propaganda for what? Have you ever seen what we as medical professionals are often forced to do, and what we say behind closed doors? This article has it exactly right. I’m a neurologist, and believe me I’ve seen more than my share of awful ways to die. Ms Wakeman, your comment makes me think you have not ever been involved in gruesome resuscitations, cracking ribs, sticking lines into any accessible body part, all the while knowing it is futile. I would be curious why you are skeptical? It’s one sided? What side would that be? That of patients suffering or doctors’ ethical dilemmas?

  36. Although my father’s chart was clearly marked “do not resciutate “, it was ignored when he was found laying on the floor by staff of the assisted living facility. He was “non responsive”, but staff initiated CPR. he was transported to the hospital and CPR continued. I arrived minutes later and was told dad had responded to CPR and his heart was beating and he was breathing on his own. When l asked why they had not followed his directives, med staff faded away leaving the Dr to tell me “no one chkd.”

  37. My Seminar in Medical Culture wrote extemporaneously on two questions at our first class meeting of the semester this week — the first question asking how they would want to be treated in the case of terminal illness (DNR? all possible life-extending measures? etc.); the second, and they did not know this was coming until after they finished the first, how they would want a loved one treated under the same circumstances (one’s spouse, child, parent).

    Then I gave them a printout of Ken Murray’s essay and the URL to read the followup discussion, with the assignment to write in their Premed Journal whether or how this discussion has influenced their thinking on the subject in comparison to what they wrote in class beforehand.

  38. Maybe then if you believe in reincarnation also, you can come back as someone or as you think some creature where you can actually do something about the problems you whine about. Their are two kinds of human beings in the world, those who sit back and complain and those who actually get off their brains and do something to make the world a better place. Your opinions on this matter don’t mean squat without action. Talking is easy, complaining is easy. Why don’t you let your actions speak, instead of being redundant.

  39. I used to care for a woman who was 105 years old. She balanced her own checkbook, and was very bright, and sharp to everything. What I admired most about her was every day she had a passion for life, and she maintained her interests as much as she could. I was encouraged by this person, and she also had some really great stories! Her family was ready for her to die, (of course she was loaded), and ultimately, this is why she died. Because she knew. Having worked with many seniors I especially love the ones who want to live. We all know this life will end one day and while we are here it is important to make the most of every second. I have enjoyed all the posts on this site. I appreciate the different views expressed.

  40. I am so glad you said this Alison! I have heard so many really positive testimonies of people with dire diagnosis, and have pursued alternative. My sister, who just finished chemo for widespread ovarian cancer, also had acupuncture, chiropractic, and reflexology. She has come a long way since she originally passed out from her overtaxed body said I need attention now! She is now cancer free, she eats a healthier diet, and she has a renewed sense of meaning to her life. I wish MD’s would venture more into the world of alternative, as I think they would be quite surprised at the benefits that are naturally geared towards helping the body function at a higher level. I will give a free reflexology to any MD who would like to try it. The combination of traditional and alternative should not be taken lightly, and without personal research.

  41. I just recalled a study also that I saw a few years ago by the Mayo clinic where two women with fourth stage breast cancer were part of a study where they were to abstain from chocolate, and alcohol while taking hormones, and herbal medicine balls from a Tibetan monk healer. Both women had good results. Especially the one who didn’t sneak alcohol, and was officially booted out of the study, but unofficially remained a part of it. A positive attitude helps a lot too:) Hope any of this is helpful for you.

  42. While it isn’t for sure a cure, I make no claim at all, however, I know women with fourth stage breast cancer who have experienced relief with Flora Essence Tea. If I may make another suggestion, look up ND Hulda Rheuger Clark, she wrote books, one called: “The Cure for all Cancers”, and “The Cure for all Disease”. She was a brilliant naturopath, and has wonderful products. In the back of her books she lists the most pure supplements available. I hope you check her website out, and her books are widely available.

  43. I appreciate the route you took, and I would do as you did. In fact I do use hemp oil (which has a nice nutty flavor) and eat a plant based diet. You are so right about synthetic meds. I am a fan of herbals myself, and I treat myself all the time. I also treat my dogs for preventative, and maintenance with herbals also. We all feel better:) So glad you are well Dave!!

  44. I admire your decision. Eating a plant based diet would be a good preventative measure for staying healthy the rest of your life, creating an alkaline environment that staves off disease I would do what you did, had I needed to make that choice. Once you start this diet it is addictive because you feel so much better. Just saying…. Each of us must live according to our own values.

  45. As a nurse I have attended many deaths. Most, 99%, have been positive.
    When the reality of the situation is faced everyone is calm…patient, family, caregiver…everyone is on the same page.
    Society has given the everyday person control over their health care. Not a bad thing if you are smart enough to know what you don’t know.
    I am a DNR. My family knows my wishes and I have the benefit of having a nurse for a sister and one for a daughter.
    Final statement: turn ALL nursing homes into hospice care facilities. You can’t get in without a DNR/DNI. This may sound cruel to the lay person, but you die a little every time you do CPR on a little old person. Seriously.

  46. Great piece. Having spent more time than I’d ever hoped for or anticipated in the hospital, including the ICU, with my husband leading up to and following a bone marrow transplant in 2011, I sympathize with your criticisms regarding quality of life and attitudes toward patients in the hospitals. However, my husband is 28 years old, and now more than 2 years after his BMT, we live a relatively normal life (albeit with a large mediciine cabinet). As the patient, or the patient’s spouse/partner/parent/caregiver, how do you discern between what I deem a very worthwhile procedure (yes, even with the chemo, radiation, months of hell, and terrifying lung hemorrhage on day -2 that landed him in the MICU, and the multi-million dollars spent on his care by our insurance providers) and a futile one? It seems the answer is in the outcome – if the BMT had been unsuccessful, I would read this piece and feel anger at having wasted the last months of my husband’s life in the hospital, watching him endure horrific agony from the chemo, instead of living at home, with eachother, and one day dying of either internal bleeding or an infection. Instead, thankfully the whole period seems like a distant nightmare, and I thank god every day for these advances, even with all their pitfalls, as I can hopefully look forward to a lifetime of experience yet to share with my husband rather than being widowed at 25. Hindsight is 20/20, as they say, and when making these decisions, we don’t know what the outcome will be. Still, difficult to fault the patients or their families for betting on faith – what else do we have? Thankfully, in our case, our bet paid off.

  47. I beat colon cancer with a raw diet and Hemp Oil.
    Modern medicine is flawed from the simple fact it is driven by the Big Pharma who also inject millions into the education system that teach doctors their synthetic drugs heal.

  48. Further, lumpectomy, radiation and chemotherapy turns a woman into a cash cow for the system. Where does it end? Treatment after treatment , follow-up after follow-up, month after miserable year of more treatment. A mastectomy gives a woman a modicum of control over an out of control situation and may certainly be more fiscally manageable. I’m not interested in filling the pockets of the latest pharmaceutical company du jours.

  49. The reasons are very clear–being cancer free and not putting poison in your body. You may not be aware of this, Tim, but there are some cancer treatments that actually cause cancer. So I’m confused. Do you think that living without cancer is no reason? Or do you think that not being interested in going through chemotherapy and radiation treatments when you can have your breasts removed is no reason? It seems like you’re more interested in womens’ breasts being intact than their very lives. Moreover, the removal of all breast tissue as a cure for early-stage breast cancers isn’t anecdotal in the least. The only reason it isn’t practiced even more is because people like you make women feel like they’ll be freaks without breasts, when this is not at all the case. Having your breasts removed when they contain cancer is a way to survive, that’s a sign of emotional fortitude and a lack of victimhood. While we’re on the topic, calling women who have had mastectomies disfigured in a public venue is utterly lacking in taste. That’s what you choose to write in a public venue following a post about a woman who opted for a double mastectomy? Why don’t you let us women worry about what we do with our breasts? You don’t seem up to the task.

  50. You make a flippant statement that the article is one-sided, yet you offer no reasonable analysis as to why you think so. Propaganda for what exactly? Propaganda suggesting that we should prepare for death instead of leaving it in the hands of relatives, who may or may not honor our wishes? Or in the hands of doctors whom we do not know? Or in the hands of a hospital bureaucracy? You may be right!

  51. This article is so completely one sided that it makes me pretty skeptical. I would not be surprised at all to find out that’s it’s a propaganda piece.

  52. My youngest daughter just posted this link to her sister’s Facebook. She and her sister are best friends. This article is especially interesting to me because my eldest daughter is a medical student in Canada and plans to practice as a trauma surgeon. She will be called upon, in her chosen profession, to make treatment decisions affecting patients in traumatic situations. I admire her for taking on such a great responsibility. Before entering medical school she worked as a paramedic with an ambulance service so she has already been in many medically traumatic situations. She also recently spent 5 weeks at the main trauma hospital in Guatemala City shadowing surgeons in the operating room, which according to her, was an invaluable experience. Thank you, Dr. Murray, for writing this thought provoking article.

  53. Good point. This may be when palliative care enters the picture. Someone with a grave prognosis (no pun intended, but maybe…) can receive palliative care on the way to recovery or hospice. I have been caregiver for a couple of old people who were on hospice but lived long enough to be decertified. Meantime, the main “suffering” was waiting. (And, of course, the expense. But it’s bad form to bring that up.)

  54. Hmm
    In one way it is good to see the important issue of inappropriate or futile medical treatment being highlighted as an issue in modern healthcare.

    On the other hand, blaming patients and relatives is pretty low! A doctor who asks “do you want everything done?” NEEDS to also explain exactly what “everything” entails, in language that can be understood by the individuals concerned. “Do you want everything done?” makes it sound like a decision between everything and nothing and obviously no relative is going to opt for the latter!

    Also you can’t just bag out Intensive Care as some sort of torture chamber without giving some credit for the great recoveries many appropriately admitted patients do make.

    I agree with many of the sentiments of the piece but a bit of balance is needed!

  55. I’ve tried to read all the responses to Dr. Murray’s superb and candid article and to the exchanges between commentators. I think my comments are not duplicative, but, if so, they were not so intended.
    :
    Death with Dignity – I read deep yearnings for the right and ability to die on one’s own terms — i.e., where, when and how — once it has been determined
    that one has a terminal illness, a state generally accepted, with exceptions in a few states, as medically-predicted death within six months. I would also add (a) a condition which is cinsidered incurable in the near future by medical experts in the field and which a competent patient (or his or her properly authorized health care proxy) has stated is intolerable; I would require reasonable safeguards to assure reliability and, with regard to an incompetent person, the same rights through the legal means of judicially-approved “substituted judgment”, (b) persons in a “vegetative state” and (c) persons in an incurable state of advanced dementia, Alzheimer’s or otherwise. I note that Alzheimer’s has already been declared and accepted as a terminal illness.

    Today, in the four states of Oregon, Washington, Montana and Vermont a patient can legally control the circumstances of his or her death – if competent and terminally ill – and doctors have no fear of lawsuits for their help in this process.
    Oregon and Washington adopted the “Death with Dignity Act” years ago through statewide popular votes, Montana achieved the result through a Supreme Court decision and Vermont did it through legislative action. The national organizations Compassion & Choices and The National Dignity Center, enlightened and compassionate physicians and dedicated citizens played major roles (for ex., Compassion & Choices brought and fought the Baxter case, which resulted in Montana’s ruling).

    Efforts to achieve the same results are underway in New Mexico, New Jersey,
    Hawaii, Massachusetts and Connecticut. With about one million voters participating last year, the measure lost in Massachusetts by less than 2%.

    Who opposes allowing such a merciful, compassionate, money-saving CHOICE
    to individuals and their families? No surprises here. Throughout the country, for over three decades, the opposition has been from two groups who have spent fortunes of money in multiple ways to defeat efforts to achieve “Death with Dignity” — the Catholic Church and the organized medical profession. The Church says it’s a matter of faith – but it insists that people of all faiths follow its views on how one should die and how suffering plays worthwhile role. The physicians’ groups — mainly specialists who earn large sums from participation in prolonging the dying process without hope of cure or renewed quality of life – say they know better than patients how much suffering is enough and deny that massive billings play any role (it’s “fear of lawsuits” and “the Hippocratic oath to ‘do no harm’ ” which actuates them, they say). Reach your own conclusion.

    What the Death with Dignity Act does is authorize a physician to prescribe,
    after a terminally ill, competent patient (certified by doctors to be the case) has so requested, repeatedly on separate occasions, orally and in writing, to prescribe a state-approved dose of a fatal, painless medication, to be taken (administered) by the patient when and where the patient chooses.

    Do you want Death with Dignity in your state? Contact Compassion & Choices and the Death with Dignity Center. Write letters to you newspapers’ editors. Talk it up. Tell your doctors you want to know his or her views — and express yours. Change doctors if necessary to get what you want..

    I have more to say about some other comments, but I want to get this out tonight.

  56. The comment by Lynn DDS is right on. Even if you have a medical directive, the hospital people often ignore it. One woman told me, “My mother had an advance directive. If her heat failed during surgery she did not want to be revived. The anesthesiologist looked me in the eye and said, ‘I don’t care about advance directives. She’s not dying on my table.'” He didn’t want the paperwork and the hassle.

  57. Hi Linda, I saw your comment and thought I would give you a link to something that might help your brother. I am in no way associated with this, I only know from what I saw on their Facebook page, that it seems like it helps a lot of cancer patients, maybe it can help your brother. https://www.facebook.com/UltimateCureSouthAfrica. Good luck to both of you!

  58. I agree wholeheartedly with your original article. I have always had a strong, strong sense of when heroics are good and when it is time to stop.
    When I was a lowly resident on a pediatric rotation at a huge hospital 1982, I was given the job of sticking new IVs and central lines into a 18 month old who had spent 99.9%of his life in the hospital, since he had been born with a congenital heart-lung condition from which he would never be cured. His mother had three other children and a husband at home, but she spent her days by this child’s side, with love and patience. One day I asked her if she ever thought about stopping all the treatments which were being given to her son daily – and she surprised me by saying “YES, all the time. He suffers so much and there is little hope.” I asked her if anyone had talked with her about choices, and in great surprise and hope she answered “Do I have a choice, a say , in what we do to my baby?” I told her she absolutely did and I told the team of physicians about our conversation. They arranged for multiple discussions with the parents and their priest, and the heroic measures were stopped and the patient went home to be with his siblings and died within a few days. The next thing I knew, the topic was being presented and discussed at a Grand Rounds simply because the idea of giving parents a choice in the decision making to NOT treat was apparently completely unusual to them. Thank goodness that since the 1980’s there has been more movement towards patients making decisions of all sorts with their medical providers, instead of the patriarchal way.

  59. I’m sorry… I stopped reading at the place where he wrote “that’s what happens when CPR is done right,” referring to CPR…

    Uh… don’t know what med school he went to, but that is precisely what happens when compressions are done too deep and NOT in line with the recommended 2 inches.

    I was a combat medic (FMF Corpsman for 4 1/2 years and I may not have been an MD, but I’ve ridden an ambulance long enough to see plenty of patients live through properly done CPR… with no broken ribs…

    So that’s about as far as I went to read the rest of the article.

    I know that Doctors also make bad patients because they THINK they know how everything should be done or how things will end up. Most of what I skimmed over seems to be anecdotal, meh.

  60. I saw the medical system do this on my mother’s last days. She was dying. They did open heart surgery on her and put in a pace maker. Her organs were shutting down and the heart surgeon argued to keep treating her. She was unconscious, bloated, poked with more tubes than I thought possible. No physician really came clean with us and talked about the reality of the situation or alternatives. It seemed we’d be neglectful if we didn’t do the open heart surgery. The last time she was conscious she was so terrified.
    I would have loved to call a minister and let her go with the family and him/her there to guide her and comfort us. Her death was inhumane. I would not put my beloved dog through that.

    Lynn E DDS

  61. if everybody would do that, millions of women would be disfigured for no reason. follow evidence, not anecdote.

  62. I just completed the American Heart Association’s ACLS (Advanced Cardiac Life Support) certification. In their materials it is stated that for the interventions ACLS suggests there is no evidence that use of the drugs increases rates of survival to hospital discharge. BLS (Basic Life Support) also has a dismal outcome for most people. Yet, this is the protocol all nurses and physicians follow. Perhaps, in our medical and nursing schools and hospitals we could offer ADS (Advanced Death Support) so those who are dying can get the support they need from people who aren’t afraid of death and can be with the dying to offer compassion, comfort, peace.
    Andrew B., RN

  63. I know what Dr Murray means and I think some of the comments are getting off track. There is a difference between prolonging death and prolonging life. Everyone experience is different but our culture does not accept death even when it could be a peaceful death with quality of life. Our culture promotes eternal “life” even if death around the corner. I agree with elaine21 comments above.

  64. Totally agree dadski! I work in a dialysis center and see this daily with patients that beg to end treatment but for the family. My husband has terminal emphysema and had his first crisis with hospitalization and intubation and dialysis which I approved. Upon awaking from five days of propofol and the vent removed he said no more intubation ever…not to safe his life. We are both no codes now. Why torture a patient with all these efforts when there is no hope of recovery!

  65. I was the doctor of record in a hospital many years ago for a family whose primary doctor was taking a vacation: the patient had “survived” a stroke but was left unable to speak or swallow and was on dialysis and a rectal tube with foley catheter: his bowel became edematous and was unable to absorb nutrients through a PEG tube. Despite a pressure relieving bed and nursing care, he developed decubitii and the IV nutrition (TPN) caused fatty infiltration of the liver and the patient completed his death process with congestive heart failure, renal failure hepatic failure and brain death. His family spent three months watching this like a Greek chorus. They refused to believe he was dead and wouldn’t let us move the body for 12 hours. They also left the taxpayer with a bill for $365000. quality of life nil, expectation of recovery nil. I believe that had they the responsibility for paying some of the hospital bill, there would have been less of an eagerness to use all measures. What his doctor and his family did was immoral

  66. I have a “don’t resuscitate order” fixed on My chart.I’ve told My Doctor that I don’t want to go under the knife anymore. I hate hospitals, I’m NOT a good patient…the beds aren’t long enough ( I’m 6’8″‘s tall)…and there are too many sick people in there…not to mention the patients.I want to die with dignity when it;s time. Remember folks…Life IS a terminal disease that is sexually transmitted.Good article, by the way.

  67. My dad was a doctor. He died a number of years ago at age 80 from heart problems brought on by smoking for 55 years before he quit. I miss him a lot, but he taught me something very important. He said that death was just as much a part of life as birth and that what was important was the quality of life and how you helped others, not the number of years lived. I have tried to live my life in the same way.

    I’m healthy and plan to live another 40 years, but I keep what he taught me in mind.

  68. Thank you for the reply, I know what you are saying, I understand.

    I was born in the summer of 1942, I’ve been a mammal long enough.

    What are the mathematical odds of mammal on a piece of spinning space rock being the highest form of life possible in an infinite universe? Use binary. Wouldn’t that be hell if mammal were the zenith of life? We are so afraid of something that is perfectly natural and if we continually worry about losing our body then when we do lose it, we have done all of that worrying for naught.

    We really need to, as a species learn humility, that we are no better than any other life form in the universe. As for the planet we are the most harmful and what should that make us?

    Had we gone back into the water as the dolphin did after evolving a suitable defense we could be swimming right now. No jobs, taxes, landlords, wheelchairs, hospitals or cemeteries. When we shed our body our cadaver would become a nutritious meal for quite a few life forms, they’d be glad to have you, feed the children.

    When the human sheds their flesh they are pumped dry and filled up with industrial waste not to come up in the food chain for quite a while and when they do, gag, gag, We are such poisoners of the planet in our ignorance. Our OS is crap.

    Highest goal I can see would be to create a wonderful world for all children, to make world peace with our blood relatives of which all humans happen to be. Instead we teach our children how to kill and then expect them to be normal.

  69. Hope the administrator doesn’t mind…shameless self-promotion here:

    Since a previous link vanished into the archives along with three hundred prior comments, here again is my blog post regarding end-of-life issues.

    http://hootsnewplace.blogspot.com/2013/06/hcr-hospice-palliative-care-and-advance.html

    The second video simplifies causes of death into four broad categories, tracking how much time elapses between diagnosis or discovery of COD and the final event — 1) sudden death. 2) terminal disease, 3) organ failure and 4) frailty. That last one takes the longest to die. But most of the time we cannot choose which group we will join.

  70. Rod, I love your attitude! We are culturally conditioned to be terrified of death and dying – death of a healthy person, of course, is a tragedy, but when it’s our time, why should we not embrace it? Having seen my father and mother-in-law ‘doctored’ to death in a manner worse than any torture the Inquisition could conceive, I hope I will be able to stick to my resolution to accept reasonable care but accept the inevitable when it comes and end my days on my own terms. Why do we give our pets a graceful exit but deny it to ourselves and our loved ones? I do understand the ethical issues, but I think the topic needs to be more openly discussed.

  71. Regarding Dr. Surge’s comment on the possible dream state of perpetual coma: I do enjoy most of my dreams (and often regret waking from them and not being able to continue or recapture them), and I have indeed wondered if there is some such subjective feeling in coma. But even so — even if I were inwardly enjoying it in some way — I could not see this as justification for long-term life support in the face of negligible odds that I would ever regain consciousness. I would not wish to spend 9 years in irreversible coma, like Karen Ann Quinlan, even if pleasurable to me, at such great emotional and financial cost to my family and the health-care system. The selfish possibility of pleasant dreams isn’t enough justification, for me, to opt for resuscitation.

  72. Mother Nature does a decent job of telling us when it’s time to shed our flesh,.

    We have been programmed and brainwashed since we were children to believe what we call death is bad. It’s not true. Shedding our mass as we zoom around a big fireball on a piece of rounding off space rock is quite normal and enjoyable if you remove the negatives from your mind and be more realistic.

    We also think that we are the most intelligent beings on the planet and have dominion over other life forms and all written by humans of course.

    I see really obese humans sitting in an electric wheel chair with a lit cigarette in their mouths. I had one female tell me that her doctor prescribed the cigarettes for her right down to the brand as she puffed away,

    My father-in-law is Dr. H.G. Scott, retired USPHS. In the summer of 04 I had an aneurysm in the base of my brain., At the time I already had my near death experience and I knew something was happening to me as my head was swirling and I felt sleepy, I knew that I may be losing my body but I had absolutely no fear, I was ready to go, Born in 1942, I didn’t mind, always looking for adventure, I figure that with eternity in the equation of life that being a human cannot possibly or logically be the ultimate.

    At 6 weeks my wife was advised that since my 99 lb frame had no memory that I should be placed in a nursing home.

    I have worked at nursing homes from time to time and an employee basically told me that they keep patients drugged until they die. LOL

    It wasn’t to be, the night wife was advised by the hospital my memory made a weak connection but just enough for a staff member to notice. I was kept another week and discharged. The last pill I have taken was in the fall of 2004.

    We humans take being a mammal far too seriously, we should enjoy our shedding of the flesh. Humans are the most destructive being on the planet and in my book that makes us the most ignorant.

    Here is the type of FUNeral I would like to have, to be cremated on a open pit bar-b-que using dried female cannabis plant as fuel. Those who are into hot dogs or marshmallows could use the flame to cook their treat.

  73. “Give me a doctor short and stout, who with warm hands and a warm heart and a genuine twinkle in his eye, tells me honestly- it is my time to die”

    Dr. Rick Lippin
    Southampton,Pa

  74. Good for you Carol! I am a physician, and would do the EXACT same thing if I was in your situation!

  75. If you go asleep, and perhaps see nightdreams, but can not ever awake – would you prefer that, in lieu of death? …And how do you know, even after decades of medical practice, that that’s not what actually happens when in perpetual coma or “brain dead”?
    (In any case, this obvious question seems to be completely omitted from consideration here.)

  76. I think H.C. workers often choose less heroics because we’re so aware of the worst case senario.

    Our intimate knowledge is at times a detriment to our best interests. We are too quick to accept, rather than suffer and fight.

    Having said that, I’ll still get a DNR tattoo when terminal.

    I don’t count on it being enough to keep me off a respirator any more than a DNR order would, just hopeful.

    33 years in Cardiology have shaken my faith in DNR orders just a tad.

  77. DNR tattoo, center chest where they can’t miss it.

    I’m going to get one when I no longer require heroics.

    If not a tattoo, at least a bracelett or necklace stating DNR.

    One doctor earlier said requesting a palliative consult and having your care transferred to a palliative care physician would work too. Perhaps you could have your attorney notified if you’re admitted to hospital, authorizing them to request that consultation.

  78. **sigh** Once again, for the record, I want to advance the argument for advance directives to become obligatory for all Medicare beneficiaries.

    I made the suggestion two years ago but this comment left last year is much better worded.
    https://thehealthcareblog.com/blog/2012/08/29/doctors-really-do-die-differently/comment-page-1/#comment-255689
    Do read it and pass the word.
    ~~~~~~~~~
    Experience shows that a majority of families of patients who have advanced directives feel that their family member had a more positive experience in the last months of life. This is validated by studies involving people in hospice and people who have exercised their legal right to death with dignity in those states where such laws exist. The question, it seems, is not whether ADs can be an essential part of both improving healthcare quality and managing costs, but how we do a better job of using them.

    I see three critical lessons from this discussion that both healthcare professionals and people in general can benefit from:

    1. If we establish a standard of discussing an advanced directive with all people, as a part of an annual physical perhaps, then the fear factor can be minimized. If the doctor can say “we do this for everyone” then those who are healthy will not fear that the doctor is “not telling them something”. I also like the idea of some kind of monetary incentive to have one in place by, say, age 55. This incentive could involve some kind of rebate or discount on services for the patient, but definitely must provide reimbursement for doctors to take the time to do it right.

    2. Note that requiring advanced directives for all people (patients and family members alike) might mean that doctors and hospitals can feel more comfortable about following them in the face of family dissent. Rather than forcing “tort reform” as a brute force method of protecting against wrongful death suits, the AD requirement might carry its own legal sanctions that addresses the ability to sue. I’m sure this is a complicated issue, but we certainly have other laws like this, so I assume the issues could be worked out in such a way as to reduce the likelihood of suits without compromising rights in cases of clear negligence.

    3. I think it might help if we make a conscious effort to recognize and verbalize the difference between how and when we apply CPR and other life-saving efforts for people with otherwise healthy bodies, and how and when we do or do not use those efforts for people with terminal illnesses or unsurvivable injuries. This aligns with the important verbal distinction often made between the negative term of suicide in an otherwise physically healthy but depressed person, and positive terms like patient-controlled death, physician aid in dying, or death with dignity in an unequivocally terminal person.

    Making ADs a standard, incentivized part of medical care, reducing resistance to following those ADs, and passing death with dignity laws in all states will have two critical effects: better deaths, and better outcomes for those left behind in the form of less emotional trauma, fewer needless services, and reduced costs. No one is happy when a loved one dies, but AD use clearly helps patients and families face the death more easily and with greater comfort.

  79. OMG now this is deep. Very deep and the truth is out . Written by a courageous Doctor Physician that whistle blows on the entire broken medical system that the general public demands blind faith and curative results from.

    I have personal experience dealing with my own Health Crisis trying to work with the failed allopathic broken system and eventually i had no choice but to embrace natural Path protocols for my complete recovery and lasting good health and I will never look back again.

    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. read more of this Holistic Chef Barry

  80. Kudos to you and your Seminar in Medical Culture. Medical schools and directors of PL1 programs must include such programs.
    I am MD1970 when the issues of death and dying were never discussed. One of the most difficult memories of my internship, was the mother of a six year old girl with terminal leukemia. During daily rounds, we barely entered the little girl’s room. One morning, two weeks before she died, her mother quietly said that the family had received much more attention before all treatment options were exhausted than now when her daughter was dying.

  81. Thank you for this thought-provoking essay. I teach a course, Seminar in Medical Culture, to a small group of top-tier premeds in a Premedical Mentorship program at my college, and I plan to give this to them next month for reading and discussion.

  82. I wish someone would address breast cancer in MEN! My brother in law has been fighting it for 7+ years and will eventually lose the battle. There are so few references, stories and I have seen no survivors. He has been on all kinds of treatment, some seemed to work temporarily others sent his tumor markers over 1,000. Any in-put would be welcome!

  83. A fantastic post, Ken. Thank you. Also, the comments are thought provoking and mind-blowing as well. Lots of food for thought and research to do.

  84. I am not a doctor and I don’t intend to die any time soon. However in May I was diagnosed with breast cancer. Before speaking to the oncologist my husband and I made up our mind what we would do. The doctor recommended breast saving lumpectomy followed by radiation and possibly chemo therapy. I unwaveringly said bilateral mastectomy with sentential node biopsy. Many people tried to sway me to a less drastic surgery, but I knew the rest was just a treatment. This was a possible cure. A month after the diagnosis I had my surgery. The pathology showed multiple lesions of cancer throughout my left breast and abnormal cells that are a precursor to cancer in the right breast. The lymph nodes were completely normal. If I had followed the advice of the doctors, I would probably have lived with cancer and cancer treatments for the rest of whatever my life was. As it is, I have been told I am cured and cancer free. People need to be informed that if found early you can shoot for a cure with some cancers. Why choose a treatment if you could have a cure? Most people are never told there is a possible cure, they just follow the recommendation of their doctor.

  85. I see the comments have once again been archived so what I wrote is no longer applicable. I do get your point, Mark. I only wish I had been better able to make mine.

    I know you asked for more empirical evidence that doctors as a group face death differently from those who are not doctors. As far as I can tell most of the evidence is anecdotal (as the now gone three-hundred-plus comments mostly suggest) but Radio Lab did a program along these lines in January “What Doctors Want from End of Life Care.”
    “How My Parents’ Death Changed My Thinking About End-Of-Life Care” by Dr. Ornstein on this blog in February may be linked below.
    And this appeared in April at Kevin, MD:

    …a 1999 study based on the responses of more than 600 US-based physicians—both specialists and generalists from private practice and academic medical centers—appeared in the journal, Resuscitation. The overwhelming majority of those physicians did not want cardio-pulmonary resuscitation (CPR) performed in the context of incurable illness, including Alzheimer’s disease, quadriplegia, metastasized cancers, and end-stage damage to the heart, lung, liver, or kidney. The doctors agreed that they wanted CPR only if they were otherwise in good health.
    http://pllqt.it/csKIs4

    I’m only leaving this one hot link because two or more drops comments into “moderation” where they may not appear for a day or two when the conversation is typically no longer fresh. I feel sure a search for those other two links will work.

    Your point about polarized arguments is on the mark. I have seen it repeatedly, most especially in arguments about healthcare and insurance reform. In fact, a couple of the now gone comments made reference to the famous but fictional “death panels.”

    Now that another trove of comments are gone I will be watching to see if this year-old post continues to get traffic and additional comments. I’ve been Web active for over ten years and this is one of the most durable posts I have seen. I’d love to know where the traffic is coming from.

  86. John, because people respond strongly to an article that is exaggerated proves my point, not contends with it. To give an anecdotal story and then spring from there the rest off the article and say ‘this is how Doctors do it”‘.
    Sure, doctors who choose to face the end of their life this way are brave and show insight. That is a great lesson and that is what people are responding to. It flies in the face of the way many loved ones use all the possible medical techniques and drugs to stave off the death of those they care for. Even when facing insurmountable odds and extreme costs. That is a great wake up call to our society.
    BUT, we also have a rising problem in our society of people exaggerating and polarizing their opinions. In doing so they write or say things that are not accurate . Especially when dealing with such a hard topic and one so challenging emotionally and financially to people, not playing loose with the numbers and facts is a little important.

  87. This was such a thought provoking and well written article. As a Family Physican I really share Dr. Murray’s sentiments and believe in the importance of quality of life.

  88. Ken, I want to point out that you are vague on some points and it weakens your argument. I’m also a doc; i share your concern about the overuse of medical intervention when it is sometimes futile. Your essay would have us think that CPR is rarely successful-I don’t agree totally and as a hospitalist, I’ve seen plenty of patients getting CPR.

    To clarify, CPR initiated outside a hospital, after a patient has had a several-minute period of pulselessness, has a poor outcome. However, initiated immediately, in or out of the hospital, outcomes are considerably better. I have an immediate family member whose life was unquestionably saved by high quality CPR. She has no neurologic sequelae, and her resuscitation lasted for AN HOUR. Fortunately, she was already in the hospital, and she had periods of having a blood pressure during that hour. But she was not young (she was 69). Your sweeping generalization is not helpful, nor is it accurate. I think we need to be more selective about who we resuscitate. The bottom line is that improved communication between providers and patients and their families would solve, or prevent, many of the problems you describe.

    At the same time, doctors pursue less care because they are more confident in being able to advocate for themselves should the need arise. Patients rarely have this luxury. They are at the mercy of our communications to them, which may be incomplete, biased, incorrect, or all three.

  89. Uh, Mark, with all due respect most readers seem not to have read the post through the same lens as yours. I, for one, didn’t interpret the article to indicate that ALL doctors are anything but medical professionals doing what they are supposed to do, deliver whatever care they can in conformity with the law, best practices and whatever advance directives may be available.

    This discussion is not about “facts” or “theories.” Please take a few minutes to read the comments and forget about being defensive about what Dr. Murray wrote almost a year ago. (August 2012) and check out the outpouring of heartfelt emotional responses among the comments. The first hundred or so are no longer available but what you see here has come in just in the last couple of weeks. This article has clearly stimulated a rich conversation about end-of-life issues and you may wish to contribute more than your harsh criticism of Dr. Murray’s post.

  90. This article is HIGHLY subjective. It only gives any factual data once or twice and the rest is all guessed at. Because one doctor in a hospital has a tattoo that says NO CODE doesn’t mean that 97% of the other doctors in the hospital do not feel the same way. Many doctors believe strongly in medicine, it is imperative in their practice and it is more common to characterize surgeons with a ‘God Complex’ instead off thinking that medicine can’t fix a situation. I think the next time you write an article like this you need to get some factual data to back up some of your theories. Maybe it is very intriguing that some doctors feel strongly one way but this article goes way over the line in trying to paint the majority of doctors to feel that same way.

  91. So often the pressure to inflict useless, painful, torture-prolonging treatments from from “loving” family members. When, my mother was in the last stages of cancer, in pain, unable to digest or even, barely, to swallow, my sisters tried to browbeat the nurse into giving her an IV to keep her alive just a little bit longer.- despite her express wishes (when she could still speak) to avoid such things.
    She had made it absolutely clear that she wanted sedation, anti-anxiety and pain meds and that she did not want to prolong the torture. But my sisters ignored her wishes and all the advice of the doctors and nurses. They wanted to “speak” with our mother just a little bit more…

  92. Thank you for this message. I agree 100%. It is not how long you live but the quality of life.

  93. Great article, and one that I appreciate. I know there are many things that can be done in medicine today, but just because you can do something doesn’t mean it should be done.

    Why put the patient and the family through it all? It just isn’t right.

  94. Justice Ginsberg must be an extraordinarily rare exception. Her survival makes me believe the Lord really does intervene in the affairs of men (and women).

  95. The decision was made by your father-in-law, not you. I’m not an expert, but I would call anything more palliative care, nothing more. What you have described has nothing to do with euthanasia. There is no need for further discussion. If you need validation for anything you did find a trustworthy counselor not connected with the family and discuss it confidentially with him or her.

  96. I totally agree. I’ve had several friends pass away at St Vincents hospice in Sydney, it is a beautiful place and everybody is very kind. What a job to work there. It takes special people.

  97. I was fully committed to doing exactly as needed, as were my siblings. However, my mum said really she would not have lasted one more day herself in dealing with things. If he had not died that day she was going to have him taken to hospital, as (even though she had been a nurse herself) it was too hard, so hard that she could not go on. Also its not just what you have to do… its the terror of whether you did things right. Giving the morphine, should you give more than before, when you know the dose is going up every time, but how much, and not giving enough is far worse than too much, and dad could no longer communicate. Basically, at a hospice, the doctors and nurses know this stuff. For us it was first time. I’m proud we made it, but i think back and i know we did some stuff wrong, and maybe we hurt him. Maybe he suffered more than he needed to? Its never good, however you do it, i don’ think it can be.

  98. So much of this resonates with me. I wish the doctors who treated my wife had been more honest, more forthright with me, but I think they did all they could.

    At 32, she went from seemingly-healthy to at death’s door in one month. Everything happened so fast, that I barely had time to comprehend one catastrophe before another hit. Had I known how utterly futile everything was, I would have made different choices for her–she was unconscious for the last few days of her life.

    I did let her be taken to ICU and it was the most horrifying part of the entire ordeal. Only after that did the doctors make it clear that her life was ending. And in my shock, I still indicated they should try and keep her alive. Thankfully, her parents and the doctors both intervened and told me I had to let her go.

    But my main source of anger over the entire thing was that her death was so awful. She died, choking and gasping for air. Euthanasia, in these circumstances, should be universally allowed. It would have saved her a lot of suffering.

    Thank you for speaking common sense on this delicate subject. I am sure there are those who would condemn you for suggesting that quality of life is better than quantity, but I firmly agree with you.

  99. Seriously shedding our mammal mass is not only normal but it’s necessary. I think that Mother Nature is the best qualified among us. Life is Energy and when energy and memory are intertwined with, neither can be destroyed.

    Hopefully we will eventually get the joke why we are mammals, orbiting a fiery ball then counting how many times we have orbited so we know what age to act, While it is true that EnergyMemory does not nor can it age since time is a made up concept that does not fit the natural law of energy. Neither does death. Change is the word, not death.

    Our mammal body deteriorates naturally and hopefully peacefully.

    I’ve had a few brushes with losing my body permanently, one from severe physical pail in 1988 for maybe a few seconds, there is really no meaning if time when shutting down so we can evacuate . I went into shock and big hungry rats could be gnawing on me and it would only tickle. Mother Nature is the very best.

    Ideally it would be nice if we thought about getting ready for the next logical step of life once we are over our prime, Unfortunately had we brought our children into a good world, fun, caring and emotionally loving, we could more easily say, “I’m leaving kids, love you:” Then leave and the family says, “uncle Joe did the natural.” and everyone smiles.

    Leaving the children in a rough world gives us a guilt feeling or should.. We would have a more youthful world if those who have gone past prime to dump their mass. A fair rule may be, if you can’t wipe or feed yourself, exit stage left.

  100. Last year, my wonderful 82 year old father in law (of 40 yrs.) entered the hospital on his own terms with COPD and several other health problems. He was admitted and, when the nurse asked about “extreme measures” being taken, he refused. No IV was started and he was given only Ativan and Morphine every 4 hours from then (Sunday pm) to the time he died (early Tuesday am). I feel that this was an assisted death, or euthanasia; no one else in our family has realized it. They assume it was a natural death. I will never say anything to them about it just because I feel that it would be very hard for them to accept. I’m in the medical field and I do understand it, I do understand it and I believe that it was merciful for him. Do you think that I’m right to believe this or do you believe that it was more of a “natural death”?

  101. Thank you very much for that information, Dr. Stein. Any of us might need it at any time.

  102. A few years before my mother was dx’d with Alzheimer’s, she have 4 hernias that were life threatening. She signed a DNR and Medical Power of Attorney to me insisting my brother just couldn’t handle it. Until the day of her death from Alzheimer’s, I was steadfast in giving her what she wanted. It was so painful for me and still is almost 4 years later. I did abide by her wishes, but still in my heart feel like I gave up on her doing it. It pains me to this day to think of the “if’s” the “should have” the “could haves”, etc. All I can pray for is that she is happy that I upheld her choices.

  103. Dear Dr. Murray –

    Thank you for your wonderful piece. Have worked in health care for over 30 years, in hospitals, home care and three different hospice organizations, as well as a kidney dialysis operator/technician.

    I must say your words and stories are a clarion call for Western medicine to take a closer look at what we do, how we do it, and more importantly, address the huge deficiency in health care knowledge of the patients we take care of. But lastly, develop a new outlook and support for health care providers working in ‘the system.’

    Currently, I work in an ER department in one of Vancouver’s hospitals. Just know I will be sharing your poignant words with many of my Facebook friends who also work me.

    Thank you again.

  104. I as a patient and a retired Medical center worker has a copy of a DNR on file at the Hospital, Dr. Office, each of my children, and at home. I know
    that I will go when the good Lord calls me and after all w all will pass on .
    Why make it harder on the family. I have seen families fight over this “should we or shouldn’t we let them live” when the patient wouldn’t like
    it..

  105. Same here Emilia! If we start it, we have to finish it.

    And, yes, TV has made people believe in the impossibly slim chances of survival. If more people could see what we really do and how it really usually turns out, they wouldn’t want to be “full codes” anymore!

  106. Jillian RN –

    Those of us who are ER docs don’t get to walk away from CPR either! And I frequently do the “rib and sternum cracking” myself when my staff needs some relief!

    The truth is, most times, I feel like we’re all just going through the inevitable steps before pronouncing them dead, so we don’t get sued. But – as of right now – we don’t have many alternatives when people don’t make their wishes known to their family members or their PMD. If a person comes into the ER via ambulance after they were “found down” we have the duty to try to resuscitate them unless otherwise noted (and notarized!). That is, unless a family member or primary care physician can tell us differently.

    Just make sure that you and everyone you know establishes their “last wishes” so no one has to do the same things to you if you ever show up in the ER in full arrest.

  107. in 1985 a routine blood test showed i had no blood. all my blood cells were more than 3 weeks old. the doctor, my neurologist, ordered me immediately into intensive care. i asked him to let me go home get a tooth brush and some books. i was ready to die but wanted to read my way away with something worth reading. the doctor said you won’t make it there and back. in fact my last memory after waiting an hour for the gurney was being rolled onto the elevator.

    it would have taken minimum 2 to 3 hours to go home and back by taxi.

    diagnosis was AIDS [before HIV] and i was delirious for a month. everything by intravenous. no food. whole blood 3 times a day. oxygen mask. if they had asked me i would have said no, let me go home and die alone in peace. nobody asked.

    eventually i developed pneumonia.

    they had immediately taken me off my seizure medications. so i was delirious, having seizures, alone, and anyone who came within 10 feet of me was in a hazmat suit. nobody ever touched me except a nurse changing my veins. no one of my family or friends or neighbors visited. i had had just enough time to call my boss [a buddhist monastery] and its rich patron to make sure my dog didn’t starve or die of thirst.

    centers of disease control never found any cause for my illness, five years later i was still getting reports. eventually i had no HIV and apparently was cured of epilepsy, but still had HepB. And antibodies for Epstein Barr. [i kept cats as well as a dog].

    many times i have wished since that they had asked me. whatever it was, it still from time to time wreaks havoc with bizarre symptoms that come then after a while go. such as the year my thyroid stopped functioning. or the time both legs went numb. or my two year bout with candidiasis. several years of Vit B 12 deficiency which i had to IM. just this year suddenly after several weeks of Hepatitis symptoms my HepB went away after 40+ years. never any HIV thank god even though in the 70s and 80s i was quite popular in the bath house scenes in NYC and Philadelphia. [i got the Hepatitis from my ex-wife AFTER the divorce].

    i don’t actually regret living through whatever it was which caused my bone marrow to turn off. but that month in intensive care alone without even myself for company just demon hallucinations was not possibly worse than hell.

    if anyone had asked me then or if it happened again now i would have said no. but nobody asked.

  108. Easiest terminal death-when everything goes right-but what happens to others?

    I was able to take time from my job in 2008, and go across the country from the West Coast, to help my mother when my father was in hospice. My immediate supervisor encouraged me to go as quickly as possible-her own father had passed while she was waiting to board her flight to see him.

    My father had been diagnosed with lung cancer in 2003, after his prostate x-ray showed bladder issues, and bladder diagnostics revealed a spot on the left lobe of the lung. He had surgery removing the lobe and limited chemo in 2003, and no radiation was required. Advanced directives-already in place.

    The cancer returned, and was addressed with the less invasive radio ablation in early 2008, but the cancer was too aggressive by then and he died at home, on Thanksgiving evening in 2008, with my mother at his side. She called out from upstairs, and fortunately my husband was there, after driving up from training in Connecticut.

    My mother is an RN. When my father retired from his job in CA in 1987 and they moved back to the East Coast (he from Canada, she from New England), she became a hospice nurse in Vermont. She drove her old Mitsubishi on the back roads, giving care to the terminally ill and their families. My father’s hospice nurse was one of her trainees!

    My friend from high school, Laurin Comeau, RN, made a visit from New Hampshire prior to my father’s death. My mother was her mentor, and Laurin had become oncology nurse at Dartmouth.

    My mother and I were able to visit the local funeral home in in Barre, VT in advance of the death. Our cousin Doug had know the proprietors of the funeral home since childhood. (I was prepped by the Six Feet Under series as to what to expect-impressive on so many levels). Doug had brought the Thanksgiving turkey that evening, and returned after the passing.

    My father had been visited by three co-workers from the California Highway Patrol just weeks before he died> They came out from CA to support the family, and also to (bravely) face their own mortality.

    A beautiful young lady/angel brought a pie to the house earlier that Thanksgiving evening.

    In short, everything went horribly right.
    But regardless, it still sucks-especially for everyone who had none of these advantages. I can’t stop feeling for them.

  109. Docs know pancreatic cancer is unbeatable. It is a waste of time and energy, which few of it’s victims can afford, to try to fight it. Perhaps you friend would have responded differently if it was, say prostate cancer where there are good treatment options, and promising clinical trials.

  110. My daughter found this article while doing research for a Masters in Nursing Course she is taking. She had to check to see if it had been written by her dad, a surgeon, as it described exactly what he has said over and over again. He died in May but had prepared us for the event many years ago having made End of Life Directives. When he was brought into the ER it was well documented. There were to be no heroics.
    I can’t say it made it any easier to say goodbye but as an informed family we had to honor his wishes for a serene death.

  111. It’s not Obamacare, but I had a similar experience with the Colorado state plan: turned down for private insurance because I had a migraine once, but the state plan accepted me (at a lower cost than private insurance wanted) and covered everything I needed for a few years until I was able to get insurance through my job again. Health insurance is one of those areas that simply shouldn’t be left to for-profit companies.

  112. As a nurse for over 30 years, my spin on this is simply that Dr.’s are not comfortable with end of life issues. I believe because of their fear or lack of educational preparation, they continue to reach for another therapy from the medical/surgical bag of tricks rather than sitting down and simply saying’I am sorry here is nothing left to do. I walked in on a dear friend age 70 undergoing chemo/radiation for a stage4 lung cancer with brain and multiple spinal metastasis. Her spinal lesions left her paralyzed from the chest down on her 2nd day of admission. I had been away for several days and found her receiving blood, and blood products because her blood counts were too low for chemo so “they needed to build her up”. Her mental state went from confusion to full alertness. Totally frustrated I asked the nurses caring for her if her oncologist had discussed her prognosis with my friend and was told Dr so and so never gives up fighting. I waited for a lucid moment and told my dear tough as nails friend that I didn’t think she was winning her battle. She looked at me and asked “am I dying” and I told her yes I think you are. With her spunky take no prisoners attitude she looked me in the eye and said” well lets get it over with then” She asked to speak to the palliative care specialist, gathered her family around her and said I love you all but I am done. She was transferred to a private room on palliative care where we sat with her as she passed from her agony in comfort and dignity within 3 days. I will never forget her look of love for me for telling her the truth and wonder sometimes how much more horror she would have endured without the truth being told.

  113. A friend of mine had lung cancer. She had surgery at Sloan K in NYC. Nine months later she had slurred speech and it was discovered that the cancer was present in her brain. She had surgery and treatment. That was 15 years ago. She is now 76 years old and very active. People have a right to try to recovery. It’s a personal choice.

  114. I had a similiar experience with the PCIP provision of Obamacare – Denied insurance after I had a stroke because of an undiagonosed blood disorder.After applyng for the coverage under the affordable care act after I was approved and then received a call from the bureau chief personally who then signed me up over the phone and I was covered and got care within weeks.

    Obamacare saved my life – the lies and misinformation are disgraceful. Everyone in our country needs health insurance so they have access to health care – glad to hear I’m not the only one who got the help they needed.

  115. It has been my experience when dealing with cancer treatment for my father and my father-in-law that the doctors pushed aggressive treatments with ambiguously worded discussions of outcomes. My father had end stage prostate cancer at diagnosis; my father-in-law had metastasized lung cancer. Both of them stated that had they know the quality of the additional time gained would be so poor, they’d have refused the radiation, and chemo, and surgeries. They had different doctors and lived in different states. Neither felt that the doctors were interested in anything beyond quantity of time. As a longtime EMT, I understood the medical jargon and options we were given, and I would have to agree that both of these men were “sold a bill of goods” in terms of their treatments. Not once was no treatment every presented as a reasonable option. Not once was it spelled out that the best case scenario was delaying the inevitable. Because of these situations, I have spelled out in written legal documents that I want NO SUCH TREATMENT should I become ill in like manner. My quality and dignity is far more important than how many months the doctor “gave me” which I think is the mindset that encourages the medical professionals to “fight” cancer. It’s not a fight- it’s my LIFE, and a disease. Electing to eschew invasive, painful and generally useless treatments doesn’t mean I “quit fighting”. It means I accepted life (and death) on my own terms.
    Teach doctors death isn’t an enemy, and you might see a different attitude displayed to patients. It is telling that doctors don’t willingly become guinea pigs themselves on the altar of Medical Research. Sauce. Goose. Gander.

  116. Thanks for this, Kelly. It’s reassuring that some medical pros are courageously sticking their necks out for patients. My guess is that once you start doing it the process becomes less ominous each time — not for patients, but for the professionals in charge. I’m sure it’s helpful to have at least one or two others with whom you can stick together.

    One compelling reason for the patient having the final word (over, say, any document they may have signed, or someone else with POA) is that without that provision many people would be reluctant to execute an advance directive, fearing that if they later changed their mind it would be too late. As long as the patient is able to indicate an opinion for or against further actions, the patient’s rights must trump all others. (Of course at some point they may need to be informed that what they want will not have the results they are seeking. And delivering that message also takes courage.)

  117. These situations are beyond unfortunate, and highlight the importance of nurses and physicians knowing their state laws. I work in an academic center in CA, and launched a workshop on advance directives this year in response to a need that was verified when over 70 staff members showed up at a class I gave with only two days notice via e-mail. The workshop has been very well attended, too.

    According to CA state law, not only do the patient’s written wishes override the DPAHC [durable power of attorney for health care], the court may revoke the DPAHC if they attempt to order any treatment that goes against the patient’s wishes.

    It may be a harsh stand, but I believe that every doctor and/or nurse who is afraid to advocate for their patient should either grow a pair or step aside.

  118. From our experience too many doctors use too many euphemisms. My father’s oncologist never made it clear to him how very low his survival chances were, never said anything like “you should be getting your affairs in order” (which he really, really should have), and grossly understated the risks of the proposed treatment –and of course this was what my father (and all of us) wanted to hear, although for those of us with internet access to research the disease we couldn’t understand how the doctor could be so upbeat. As a result, my father wanted to “do everything” and never seriously considered nontreatment as an option. Radiation severely damaged his brain, and instead of spending his last six months with is family, he spent it in wandering dementia–but still aware enough to be horrified whenever the word “hospice” was mentioned, and still expecting that he would receive a treatment that would cure him. In the meantime, when he had to be admitted to the hospital twice for a raging urinary tract infection, my mother was pressured by emergency room doctors and rounds internists whom she’d never met before to sign DNR orders, which they did not adequately explain to her, against my father’s wishes. An impossible position. I think we ARE too much influenced by TV, movies and the high profile miracle cure stories we see in the newspapers, and we don’t want to give up if there is a real chance of survival with some appreciable quality of life. Primary care doctors have a hard job, but they are the only ones who can really convey the hard truths, and if they shy away, or use blow softening buzz words or euphemisms so that the patient isn’t told clearly what is going on, they contribute to a great deal of suffering in the long run.

  119. Kevin-I work in the CVICU in a large medical center. We routinely have patient’s from care facilities come in with out of hospital DNR’s on the EMT clipboard who are intubated and sedated in our unit because the medical power of attorney wants it done. One patient, as 92 year old man, has been in our unit five times in the last year on the ventilator. The patient has had multiple strokes and can no longer speak for himself. The ER physicians know that patient well and always proceed with the treatment the MPOA wants. I call it “commando medicine” because all are afraid of being sued for going against the wishes of the MPOA even though the patient has proper documentation of his wishes. The MPOA, his son, avoids attempts at education by not coming to see his father in the unit. It is soul crushing for most of the staff who care for him.

  120. My father had a DNR, a very clear and detailed list of what he wanted and a cooperative understanding Dr. At his end, we four daughters had to fight to keep his nursing home nurse and covering Dr. from sending him to the ER and getting a lot of testing and procedures done. They thought he might be obstructed and wanted to do tests and maybe surgery. His desires were not even an IV. If we had not been quickly available and argued very forcibly he would have been sent. They had the paperwork all filled out and a transfer bed parked out side his room. All hospitalized patients need an educated advocate.

  121. Great comment. I have also worked in the ED in Australia. I wish the public was made aware of the extremely low success rates of CPR. Over here, if a patient arrests on the ward and we start CPR, we must keep going until a doctor decides to stop, even if it is very obvious from the start that it won’t be successful. It’s an awful situation. Also, if the patient had a DNR but someone started CPR by mistake, we must continue with full measures from then on. Ugh.
    And for goodness’ sake, can the TV shows please stop shocking asystole? 🙂

  122. What a great article, even if some details were a bit fuzzy. Very compelling to read. I am a nurse working in Australia, and my colleagues and I frequently talk about what sort of measures we would want for ourselves, if we were to become very unwell. What would we want done if these patients were our parents? I was once told by my student mentor that sometimes, after a sudden event (MI, CVA etc) where the outcome is poor, the patient will be sustained on life support while the family can come to terms with the situation – and eventually make the decision to remove these measures. To me, this is appropriate. What is inappropriate (in my eyes) is a family choosing to prolong the suffering of their loved one when they no longer have a quality of life. It can be so sad to be nursing a person who shows so clearly in their eyes that want to die, but are unable to.
    May I also say that it still shocks me to hear about the health care system in the US. Here, if you find out you are sick and need immediate treatment, all medical costs are ALWAYS covered by our medicare system. I don’t fully understand the American system, but it chills me to think that a person’s decisions for their health and well-being could be dictated by money!
    And finally, a DNR (or NFR in Australia) tattoo or bracelet will be ignored in a life-threatening situation because it is not a legal document and the order may have been changed since the tattoo. Not that many people would opt for this anyway! haha.

  123. I had a friend who died 5 years ago, in his early 50’s, of cancer after a decade-long struggle with different tumors and surgeries and losing both legs. Eventually, one if the metastasized tumors – usually caught in time – proliferated and he was too late. In his final 2 months he chose hospice care and was given control over the amount of pain killer he wanted for dosage. I could see the wisdom of patients deciding their own pain schedule, but I also wondered if this was a nod and a wink to letting him choose the time of his own death. Although I was his best friend, and apart from his wife the only one present when the ‘you’re terminal’ conversation took place, I never felt comfortable asking him.

    But, he’s a smart guy and I’m sure he could have figurd that out himself. He chose not to overdose himself, even when one of the many tumors that sprung up in the final weeks pressed against his larynx and he could no longer speak. He had a few more weeks of friends and family visiting and played a few more hands of online poker. He slipped into a coma and left, I truly hope, in peace.

    But I still wonder if he ever considered using his self-dosing as a mechanism. (A “House” episode has House presenting, under a false name, a scenario where a Doctor mentions in earshot of the patient the code for controlling the dosing – and the patient takes advantage to end his or her life).

  124. Sean, I hope you are healthy and when you die, you die in your sleep. I work in ER. I have DNR( do not resuscitate) or NO Code orders. Do you know why? Because in 20 years in ER I broke plenty of ribcages, seeing more penises on dead man and breast on women who would be ashamed of what we did to then in our effort to resuscitate .None of them survived long enough.Breathing tubes, IV’s, Foleys: tubes sticking out of every hole in your body , brain is dead but body is here………Its not about death panels, NO ONE lives forever. We all die. Just a few of us can do with dignity. I hope people in ED, where your lifeless body arrives , have enough courage to stop useless CPR. Because unlike on TV, we do not shock systole.

  125. @sam — The orthopaedist didn’t devise the procedure, the surgeon who explored his lump did. Read the paragraph a bit more carefully.

  126. i wonder how (n why) an orthopedist invented something to triple survival in pancreatic cancer pts?

  127. This really hit home with me. My father, age 76, had an aneurysm to the brain while watching his favorite TV show in his recliner…perfect way to go. But…even though he had a DNR, my Mom called the EMT’s, who brought him back. They airlifted him to a local hospital, who put him on life support. That was on a Tuesday. On Thursday, we finally talked to his neurologist after many tests. He told us that my dad died on Tuesday, but his body was still here. We signed the papers to remove him from life support the next day, Friday, his 77th birthday. Four very hard days in our lives…but he had what a friend called “a good death” as he didn’t suffer for years with Alzheimer’s, dementia or worse. When it’s time for me to go, I hope to go the same way. I totally respect all of these doctors decisions. Just live your life as if it’s your last day, because you never know when it will be.

  128. john….where are you getting your info?…..because it hasn’t even been funded yet due to the filibustering congress………

  129. @Sean B — There are no death panels. Yours is among the most misinformed and mean-spirited comments in this thread. You describe yourself as “extremely conservative” but ignorance gives Conservatives (or Liberals for that matter) a bad name.

  130. Thank you for a nice piece, dr. All I can say is that this type of reading should be mandatory for peeps when they sign up for Medicare. Also the dr. should NOT have to discuss this with the family of a dying patient, there should be an admin/bean counter to tell them the facts of life (death). I am extremely conservative and hate everything about Obamacare, but the one thing he had right was the creation of death panels. There is a great conservative case to be made for death panels. Unfortunately, I am alone. And EVERY single time I explain this to people, they start CRYING. WTF? We apply a cost/benefit analysis to everything else we do, why not this?

  131. As a 70 year old MD with multiple sclerosis (I am still ambulatory), I have made it clear to my three children that under no circumstances do I want CPR performed on me. I am adamant about never being admitted to an ICU. In the event of a terminal illness, I want hospice care, which not only cares for the patient but also the family.

  132. I have seen this endless heroics have far too many time and it happens pretty much how he described it. A family member is suddenly faced with the loss of a loved one, they grieve, they panic, they grasp for hope……one more day, one more week, or a miracle.

    Why families sit at their loved ones side, we do what they ask. There is a great video series basically goes through the life saving measures we provide at the end of life. It actually shows real patients. The hope is only then will the families understand what we are trying to explain in regards to end of life care.

    I have never known a Doctor to want to provide unnecessary care unless they are doing so out of fear not greed.

  133. Oregon received a huge federal grant in order to attempt to solve the healthcare finance crisis. It will be years before all the kinks are worked out. I am happy to hear that you were able to receive the care your family needed without going bankrupt. That’s what I love about Oregon. Now, if only the rest of the country would figure this out.

  134. This is an interesting article on how doctors make different choices for their own care than their patients often do. It is interesting in that they do make different choices at all, and what does that tell us poor lay-folk who are going bankrupt over the cost of health care that a doctor doesn’t even want? The one big thing it fails to mention is how much money plays a part in all of this. I find it hard to believe that patients and their families are convincing doctors and hospitals they need surgeries and treatments in a state confusion and desperation, as this article would have you think; in my experience it is the other way around. And while maybe there is some truth that they are concerned about being sued by angry families, it would seem the larger reason, the umbrella cause of all this suffering, is to make money.

  135. Imagine now how the nurses who have to administer such care feel about it. In reality, the doctors get to walk away at the end of their 15min with the pt. They rarely do CPR so they don’t have to feel the ribs and sternum crack, they don’t have to suction the patients that are drowning, or hold a family member while they grieve. The don’t have to watch the pt get agitated, grimace, and moan through the night. They can generally write their orders and leave. If MDs have high rates of depression and drinking then nurses have more…

  136. I must take umbrage with your opening anecdote. You didn’t provide enough information to determine whether the orthopedist with pancreatic cancer made his decision from a perspective of knowledge instead of fear. The medical literature has cited oncologists’ defeatist attitudes towards pancreatic cancer as contributing to the disease’s poor survival rate. Too often, throw in the towel is told to early-stage patients who might benefit greatly from treatment.

    In fact, I was diagnosed with pancreatic cancer over three years ago at age 42. I had chemo, radiation and the horrible surgery. And–guess what–my quality of life is not poor. Far from it. By virtue of a facebook group to which I belong, I ‘know’ hundreds who would say the same.

  137. Teri. I surely feel your pain, for both you and your son. I am a massage therapist and am studying a modality called Structural Energetic Therapy®. I have a client who has ankylosing spondylitis. We have had 2 treatments so far – a cranial structural core distortion release and 2 series of pelvic balancing. For the first time in a long time, she was able to do things around the house (laundry, cleaning and even mowing the lawn) all in one day with minimal pain, rather than a little piece each day in excrutiating pain. She also reported her pain level to be 5 to 6 on a scale of 1 to 10, rather than a 9 or 10, as it was the first time I saw her. Yesterday, after our session, she told me she did not experience any pain for a few hours that evening. While this isn’t a cure all, if it can help with the pain your son is experiencing, I would certainly think it would be worth looking into. I am expecting that with further treatments on the different areas covered by this structural modality, my client’s pain will be all but completely gone. Even if it doesn’t completely get rid of her pain, a pain level of 5 or less is certainly better than 9 or 10. If you will take some time to review their website, you might just find some relief for him. http://www.structuralenergetictherapy.com.

  138. LOL, Eric….well, in our fantasies, perhaps…and, certainly NO ONE has more reason to do so…..

  139. I am married to a pharmacist that hates to take any medication!! I think he sees the abuse & doesn’t want any part of it!!

    I believe doctors see the unnecessary & costly procedures & know the futility of prolonging the inevitable( in some cases) and don’t want any part of it!!

  140. I’m so happy for your choices and your use of alternative treatments that seem to have improved your health. Some of these treatments are considered “radical” and doctors are not usually allowed to discuss them with patients. I’m glad you were able to try out alternatives that you found more appropriate and that you have improved. Thanks for sharing.

  141. Great thing to have however, don’t be surprised if, in an emergency situation where an ambulance is called, the paramedics overlook it. It’s YOUR responsibility (meaning the responsibility of whoever called 9-1-1) to give it to them. They are too busy treating the person who the call was placed for to be looking around for paperwork.

  142. No one is blaming the doctors, per se. Doctors can only do what you or your health care surrogate allow. If the doctor is led to believe you want everything done, they will do it. It is up to the health care CONSUMER to educate themselves and to know what they are willing to endure to live.

    As for the poor 100 year-old woman who was intubated in the ER before her family arrived…as a former ER nurse I can tell you, in an acute situation we do NOT have time to ask about paperwork….especially when there is no-one with the patient. We treat first, ask questions later. The family handled the situation very well.

  143. I recently lost my husband to lung cancer and he thought long and hard about Chemo and radiation treatment and after going one round with both decided on a DNR and Hospice . He live almost four more years in quality care without the sickness of Chemo and burning of radiation. He died at home peacefully and was able to travel during those 4 years and see much of his grandchildren which were the Joy of his life. He chose to live without treatment with dignity and peace of mind. What a wonderful perspective this Doctor shares!!! It was a choice my husband made also and gave the quality of life he wanted and we shared that together.

  144. I don’t see any mention of the POLST form that my parents have signed, had witnessed, and have copies in an envelope on the side of their kitchen refrigerator. The Physicians Order for Life Sustaining Treatment forms clearly state the level of treatment they want, which matches what their Medical Directive and what all of their kids know about their wishes. It is in writing and properly documented. I will have the same in place soon. My folks are in their 80’s and know that medical bills can be devastating. I appreciate their foresight more than words can say!

  145. Kristin and Kevin:
    Interesting conversation. The ONLY way a legal DNR can be overturned is by another legal binding DNR. I have worked for several years in a ED. If the staff of Doctors and Nurses had strong ethics, a “word of mouth” cannot overturn a legally binding DNR. Maybe different in your states, cut and in Wisconsin!!

  146. I too, my DNR, advance directive and medical power of attorney are all in place.

  147. Unfortunately, I believe this pool of money has run out. It was a well intentioned piece of legislature but not properly funded, especially for the type of patients it is meant to help. These patients frequently have medical costs over a million dollars.

  148. What do you do when you don’t *have* anyone to act as your agent to make sure your directive is carried out? For reasons I won’t go into here, I don’t have anyone I can give this responsibility to, and I’m more than sure a lot of people are in the same boat I’m in. Yes, I have a directive filed with my HMO, but is that enough?

  149. My mother, a 67 year old with end stage COPD (among other dx) was diagnosed with severe aortic stenosis. The cardiologist wanted to do a cardiac cath on her. At first we were under the impression that he might be able to repair the valve with CC. When he explained that the cath was so he would know how many vessels he would have to bypass mom & I had a long talk. She was mentally intact. I explained that with her level of COPD she would either not make it off the table or live whatever time she had left on the ventilator. She decided to go home & lived about 5 months. She passed away on her couch, in her own home, caring for herself (with some help from her children).

    I wish we were able to lay it out for family members in this manner. Very few “get it”.

  150. Kristin-That’s unfortunate that you’ve seen that so many times. I believe you that in the real world it does occur often. From what I was taught in medical school and what I tried to confirm online, the official rule is that the DNR over rules the health care surrogate. The doctor and hospital can actually be prosecuted if they proceed with “life saving measures” contrary to a DNR in front of them, but I can definitely imagine in the face of familial pressure a doctor could do simply what the screaming family wants.

  151. Kevin, unfortunately in my 13 years critical care, I have had family members revoke DNR’s. They Can and do do it! Ethically it’s not right, but when families get assertive and use the words “lawyer”, the doctor feels personally threatened and proceed with life saving efforts.

  152. In response to Robyn- a legally authorized DNR signed by you is not allowed to be overturned by your health care surrogate. Who is your health care surrogate? That person is someone you legally appoint or is determined by closest family member (spouse, parent, child, etc)

    On a practical level, it’s important to discuss your wishes with your family as often the case is that a patient will come to the ED without any accompanying documents. The ED doctor will “do everything” in the absence of such documentation (i.e. DNR). Your family member may come to the ED and also say that they want everything done. However, when the appropriate paperwork (your DNR) comes, the doctor will follow those written documents over anything that your family or health care surrogate says.

  153. Once again, let’s blame the doctors! When will our society learn that each of us need to start being responsible for our own HEALTH and CARE! While I believe that it is true that many physicians will not go through extenuating circumstances to prolong their life through unnecessary treatment, I believe it is because they are educated. Physicians do not spend 1/4 of their life obtaining the skills and rigorous training to “Make money by ordering unnecessary tests and procedures,” they do it because they want to help and cure people. I am tired of our society targeting this profession and not taking responsibility for their own actions. Ask questions!!! Do research!!! Educate yourself!!! A physician works for you and if you don’t know the answer and cannot find reasonable solutions they work for you to provide answers. If you don’t agree with something SPEAK UP and ask for a “reasonable solution.” Physicians want to help you and if you don’t like what they tell you…it is YOUR responsibility to seek out a second opinion.

  154. This is very true. My mother was diagnosed with stage 4 colon cancer in 2000. She had surgery and did chemotherapy, resulting in 6 years remission. She had three subsequent recurrences, which involved surgeries, radiation (one round), and two-and-a-half more rounds of chemo. She died last month, peacefully, having long ago talked with my brother and me about her wishes and given us the legal authority to make certain they were honored. Caring for her was an honor and a privilege, and it was a gift to be able to help her manage her pain without having more inflicted. The thirteen years following her initial diagnosis also allowed her to see us with our own families, and her biggest delights were the grandchildren she would never have known (and who would never have known her) if she had made different decisions. I definitely would never tell someone to pursue treatment if they didn’t want to, but I’m grateful that it was an option for her and that it allowed her to know and love them, and vice versa.

  155. After excision of a mixed tumor of the parotid (Salivary gland) and 33 radiation treatments for a low grade carcinoma in the outer margin, I was diagnosed with pancreatic cancer. Oncologists and surgeons recommended that I proceed with the whipple surgery……….After reviewing the procedure on the internet and consulting with other dr. buddies, I concluded that the Whipple was not the way to go………………As a Christian, I know where my future is and I elected to not accept my drs.’ advice to have the surgery. By prayer and God ‘s grace, I was advised about the availability of the use of a radio frequency machine for non invasive treatment. I also used deionization, diet changes, sunshine and ingestion of many vitamins. After three months of many prayers, the abnormality in the head of the pancreas was no longer present…………

  156. When my father had esophageal cancer he did chemo, radiation & had surgery. He lived a quality life for a year or so, but the cancer came back. The doctor gave him six months to live although he said he could do chemo & radiation again to prolong the inevitable. He was always sick & felt miserable with those treatments in the past. He felt it was pointless to prolong suffering, he couldn’t eat & all he did was sleep during treatments. He knew he was eventually going to die, but he didn’t want to suffer for a few more months so he could suffer & die later. He refused treatment, was placed on hospice & died at home surrounded by his wife, children, & grandchildren exactly 6 months later.

  157. I remember my grandfather who raised me since I was a child. At the age of 80 he was bed-ridden due to numerous illnesses he had. Because of his condition he had aspiration pneumonia and eventually got weaker. I treated him at home and even turned his room to a regular hospital room (with the help of my brother and aunt who are nurses). Our neighbors would visit him and they will sometimes comment that it would be best for my grand dad to be put in a hospital where tubes and monitors will be in placed. Then, I remembered what he told me when I graduated medicine that if his time comes I will let him go in peace.. So I continue treating him at home with no advance life support and when he died on his birthday I can see in his face that he is very happy.
    During his funeral I heard people talking that I made a bad decision as a doctor not bringing my grand dad to the hospital. It really made me sad. Then I realized, I still made the right decision because as a doctor you know what is worth fighting for and what is worth giving up. I always encounter in the emergency room relatives will often tell you to “do everything at all cost!” but I think they don’t really know what it means..
    When my time comes all I want is to be with all my love ones holding their hands and not in a hospital bed hooked to monitors and on ventilator….

  158. Your family needs to know and understand your wishes. Despite a DNR, decisions are left up to the healthcare surrogate.

  159. May I share your story, BR? I have been fighting a losing battle with the anti-ACA folks…..BTW, I no longer have (and haven’t since 2003) employer sponsored insurance. My private insurance (that covers myself and my 21 year-old son is $1400/mo…..I can barely afford it. I was turned down for cheaper coverage due to preexisting conditions (past treatment for breast cancer for me and my son has an auto-immune disease called ankylosing spondylitis- a type of arthritis). I eagerly await the “pool” so that I can shop for more affordable insurance and not be told I don’t qualify…..

  160. @Cherie Magee This comment thread has become so long that hundreds of comments no longer appear. (Notice the date of the post — 2012)
    I have left the link below a couple of times before, but here it is again — a couple of informative videos and further links underscoring the importance of advance directives for medical care. Everybody should have one, filled out, signed and legally executed, which includes the names and contact numbers of at least three agents for medical care decisions. Your agents should know who they are, where to find your paperwork and have all agreed to the responsibility. In some states to avoid a conflict of interest, agents for medical care (named in your Advance Directive for Medical Care) cannot be the same as whoever may have Power of Attorney (POA).

    Your advance directive should be reviewed and updated at least every three years. Medicine and science changes. Agents may change their minds or beat you to the end of life. And you may simply have changed your mind about something.

    There is plenty to learn and do in advance of the need. And be aware that all that planning may not be necessary if you are still able to communicate for yourself. Your agents are only needed if for some reason you cannot communicate (for example, if a medical procedure goes horribly wrong and you are comatose, or if you have brain trauma (stroke or accident) which leaves you incoherent.

    Here is the link I mentioned. It leads to two additional links, but I have learned in the past that if I post more than one hot link at this site the comment is automatically held for “moderation” and may not appear for a day or so.

    ==► http://hootsnewplace.blogspot.com/2013/06/hcr-hospice-palliative-care-and-advance.html

  161. Do an internet search for the pills and potions that you are using and decide for yourself if side the noted side effects are okay with you. I had an aneurysm in the basilar region of my brain in the summer of 2004, at 6 weeks I was ordered to a nursing home as I had no memory, I was a 99 lb male heading for deaths door.

    My memory made a weak connection which saved me from a nursing home and being medicated until I die in the not so distant future. I was taking Dilantin only when discharged and read the side effects online, , better yet I was living them in person, they are horrible, more than horrible and were given me to dilated my blood vessels.

    A few days ago was my 9th anniversary from the stroke, I gave up all pills in 2004 after taking Dilantin for 4 months, 4 long agonizing months. Then I learned that the active ingredient in the female marijuana plant dilates blood vessels naturally and it’s side effects are wonderful. All I use is medical marijuana and on my b’day in a few days I’ll be 71. I have no paralysis, I have a good supply of energy, I can run a bit, work for hours and keep up with others who were born long after me.

    I eat healthy when I eat but the 3 meal a day public health department guideline is deadly and in serious error. For over 35 years I developed a habit of eating my first meal of the day after work and drinking water only during the day. 1 meal a day is more realistic and healthy for our species of mammal. 3 times plus snacks is unhealthy.

  162. This is so true. I have been following a “let nature take its course” plan for several years now. I even had a doctor tell me to find another doctor but no one tells me what are life threatening and to refuse treatment and what is relatively minor and take treatment. At the moment, I am taking a blood pressure pill and Spireva. I wish there was good advice available to know when to stop taking medication which is the only medical advice I have ever been given about my plan. Don’t medicate.

  163. This is a timely piece for me to read. Five years ago on the 30th of July I lost my wonderful, loving husband Joe. He had a local trucking business and needed surgery for pain and numbness of his right arm. Thus he underwent a series of horrible accidents; 1st surgery was done after testing his nerves (heinous for those watching), he had major surgery of his neck and was sent home. He did the necessary rehabilitation and fell at home not while I was watching; he was sent back for a second surgery where it was said (by him) that his head fell off of his neck). Nothing was ever right after that. He refused to shower for six months, he couldn’t get off the ventilator, no matter what he did he couldn’t do it. Now I know in reading this post, nothing I ever did would have ever been enough. In thanks for the beginning of the grieving process.

  164. Almost 40 years ago I worked nights in a hospital as a certified nursing assistant. I was 18 years old. One of the duties of the night CNA was to give the preparatory enemas to patients undergoing diagnostic testing that day. One night, I was working with an elderly woman with a diagnosis of advanced cancer, in pain and very weak, but lucid. She was scheduled for a barium enema, and I was to do the prep. She told me that she didn’t understand why she was having the test, didn’t want it, and wanted to be left in peace to die. I talked with her for some time, then quietly said ” if you refuse the preparatory enema, they can’t do the test.” She looked at me with gratitude and shook her head no. I reported the refusal to her nurse and she was spared the procedure.

    She died the next week.

    I will never forget her, that 5 am conversation, and, at such a young age, the sense of clarity about how senselessly the medical system can treat suffering people.

  165. I have always felt that Doctors themselves wouldn’t put up with what the average person goes through at end of life! So I guess it is true. So what exactly needs to be said in a written request to NOT perform certain treatments? A DNR doesn’t seem to be enough…what are your suggestions? I am in good health at the moment but anything can happen…and my mother who is 85 now and overall is in great shape, says all the time when she sees people who are sick and suffering “if I ever get like that, just shoot me!” She hates hospitals! She would be so miserable sitting in a hospital for weeks on end. So what is really necessary to insure no one goes to extremes in keeping either of us alive?

  166. This is our true story about Obama Care,
    In 2010 my wife and I, both retired and in our early 60s, went to a local insurance agent to secure private health care. We were both turned down for coverage. I was turned down because a minor, pre-cancerous lesion was removed from my face several years earlier and Barbara because she had had a hysterectomy 15 years earlier. We didn’t smoke or drink and enjoyed reasonably good health over the years. After this first rejection we applied through a different agent. This time I was approved and my wife was turned down because she had a minor, laparoscopic procedure on her knee 2-3 years earlier.
    In the summer of 2011 Barbara was diagnosed with stage 4 esophageal cancer. After this devastating diagnosis and being well aware of the financial realities related catastrophic health emergencies my next stop was a bankruptcy attorney. This is what he told me, “In Oregon, a medical facility has the right to take everything a person owns except for $50,000. “It is the law of the land”, the attorney explained, “The medical industry can set whatever price they want, there is no control over what they can charge and they have absolute collectability. “ And so, it should be clear to anyone reading this that we were drowning in fear and despair as we faced a life threatening illness and financial ruin at this late stage of our lives.
    Soon after the above events our daughter called to tell us she thought we would qualify for the Federal Medical Insurance Pool, (FMIP is Obama-Care). I checked with a local insurance agent who told me we would not qualify. But later my other daughter called, telling us that it appeared Barbara would indeed, qualify for FMIP benefits and faxed the application to me. I called the number on the FMIP Application, expecting to wait on “hold” along with a series of pressing 1 for this option for 2 for that option and was surprised when a woman answered the phone directly after the second ring. I explained our situation; having lost employer sponsored health insurance, having been turned down for private health insurance and now the necessity for immediate treatment of my wife’s catastrophic illness. We faxed our application to her and were informed within 2 days that we met the criteria for ObamaCare and that our coverage would begin the first day of the next month. About a week later the cancer treatment hospital called asking “how we would be paying for my wife’s treatment.” I told them she had been approved for the FMIP ObamaCare. They checked their records and already had the necessary information for my wife to begin her treatments.
    There is a lot of mis-information out there about ObamaCare and I just want people to know that because of the fast and efficient response from ObamaCare my wife and I were able to battle her devastating illness and not have to live with distraction and the fear of financial ruin.

  167. Beautiful blog. My 100 yr old grandmother was rushed to hospital in heart failure – by the time family arrived she was intubated even tho she had a Living Will – the hospital refused to extubate her and take her out of ICU. My mother called and said what do we do? I told her untie her hands, she’ll pull the tube out herself. And Voila – 5 minutes later she was extubated, and transferred out of ICU soon after. She lived a few more days with lots of visitors and humor and cookies, and died peacefully the day of discharge.

    When my uncle was in a vegetative state after a devastating MI, with no hope of recovery, the doctor in charge refused to withdraw life support, even with an Advanced Directive. My aunt called and said what do we do? I said go to the nursing station and request a Palliative Medicine consult, and when they arrive, request a transfer of services. Done. He passed away peacefully a few days later.

    Sometimes you have to be your family member’s advocate for a peaceful death, as much as when you want treatment.

  168. This is a timely piece for me to read as I am currently working with a woman whose father is dying of esophageal cancer. He has undergone multiple rounds of chemo that have no chance of curing his disease. Multiple blood transfusions. Radiation. He is incredibly sick and miserable. Cannot talk. Cannot eat. Cannot do much of anything. He endured all of this treatment because his family panicked at his diagnosis of Stage 4b disease and could not bear to let him go. He is living the most marginal of marginal lives. And watching all this unfold, I thought, how can I avoid having this happen to me? I am going to make sure I have documents and legal papers explaining exactly how I want to die prepared and ready to go. No one lives forever and yet so many people are dragged through unspeakable pain and suffering as they approach the final door. I would rather walk through of my own volition, whistling and waving to my loved ones, if I can.

  169. Todd, I’m very sorry about the loss of your mother. That was very sudden. I’m glad that it worked out for you and your family were able to join together to offer your mother the gift of a peaceful death. God bless and comfort you and your brothers.

  170. I took care of my mother-in-law, mother and father at home with home hospice care. I have been a nurse for 30+ years. No science projects, just morphine for pain as needed and valium for anxiety. Father and mother-in-law lasted 2 weeks….mom went on for 3 months. Not easy to do, but it is the best way for the patient. No feeding tubes, IV’s, chemo, etc. Terminal is exactly that and modern medicine can only delay the inevitable and at what cost emotionally, physically, and psychologically? Let me die at home and let me do whatever I want for as long as I am able.

  171. Actually, heaven does come as a free gift. Salvation is absolutely free. You cannot earn your way into heaven. No good deed can get you there. The Bible is very clear about that. I Do think it is a very wonderful thing to care for an aging or sick parent just as they took care of you when you were little.

  172. It strikes me that we let our pets die more humanely and gracefully than our human family members. Wish that death was more simple and natural, not a science project in prolonging the inevitable.

    Thanks for your thoughtful comments, from a young(er) person who has never really seen death, they are quite meaningful and insightful.

  173. Study and documentation of the efficacy of non aggressive ancient cures would arm the MD with gentler alternatives and documentation to shield them from professional harassment and the notorious law suits.

  174. The desire to fight disease is as old as man. Many ancient herbs and cures are neglected because they are not patentable. Drugs once off patent that are found to help other off patent diseases are not pursued due to lack of profit. WHAT THE SYSTEM NEEDS is a massive study of common, not patentable, herbs, foods, compounds to define their properties and uses. For example, turmeric was found in actual lab tests to kill cancer cells but there is no incentive to pursue the study. By the bye, India where tumeric is part of the diet has a significantly lowere cancer rate.

    How can we kick off this type of study? I worked on getting a man on the moon at great expense and with lots of technical fallout. Perhaps something similar is needed for medicine!

  175. Nathan, you make a good point. Many people are not in a position to shift gears and stop everything, even if they get the ultimate of all bad news, a diagnosis of a terminal condition. Your letter underscores the importance of responsible financial planning which has more to do with peace of mind than the acquisition of wealth. The ultimate safety belt, of course, is a good term life insurance policy, which most people consider something that they cannot afford as long as they are still struggling to make ends meet from one payday to the next. In that hamster wheel life insurance premiums seem like a waste — like spending money on lottery tickets or entertainment. I know. We’ve been there.

    But the fact is that life insurance is as important as any other — fire, auto, health, etc. And the good news is that it is also surprisingly inexpensive for young people. And the younger you are the better bargain it is. But you need to be a good consumer and buy term insurance only. No “investment” plans or “whole life” or any of the other smoke and mirrors products that the industry peddles that insure good commissions to their sales people.

    Tem insurance will not be easy to find, but a stubborn consumer can get it from just about any company. You just need to be persistent. No “cash value” or “borrow from your plan” need be included. If you are in your thirties and in fairly good health you should be able to be insured for half a million dollars for well under a hundred dollars a month. And for a lower rate you can still leave behind a pretty good amount. If you have children this should not be a hard decision.

    As any salesman will tell you, that money is not for insurance as much as it is for peace of mind. (The bad news is that you are far more likely to be disabled and live than to die, so disability insurance costs a lot more. Sorry to add that down note, but it also needs to be said.)

  176. Lewis Thomas’ “Lives of a Cell” prescient as ever. What choices do doctors make for themselves and their families? They tend to utilize the system and opt for treatment much LESS than they prescribe for their patients. That is the key point the author is making. Whatever your values and beliefs (and don’t think all doctors share all of these), when the doc says “If you were my father/brother/son/self, this is what I’d advise”: they are mostly deceiving themselves.

  177. I want to thank you for sharing such an article. For years I have battled with my own personal beliefs on the subject or death and dying against what I have been trained to believe on a professional level. I have worked all my professional nursing life in the field of Cardiothoracic Surgery and I encounter death on a regular basis. I often went home upset and depressed when I witnessed (and participated) in aggressive management + treatment of a patient many of us agreed would not see out another night. But they often do, brought back from the brink by some short-term medical intervention that buys them an extra few days of misery. My grandfather passed away from terminal lung cancer when I was thirteen. He was in hospital for over a month with a chest drain insitu but nothing was improving. He was 78 yrs old and smoked heavily for most of his adult life. When his managing team found out his cancer was terminal, they spoke to my aunt and advised her to bring him home to live out his final days in familiar surroundings, amongst familiar faces. As a young teenager at the time I did not fully comprehend the significance of their decision, but I sure do now … and I will forever be grateful that my grandfather was able to die with dignity and he wasn’t alone with tubes down his throat. He wouldn’t have liked that very much.

  178. As a quick follow-up, what all of the extra care is really providing people is hope. And that can’t be dismissed. Even if the numbers aren’t good, people still need to have hope that they’ll be in that minority and live an extra 5+ years. Many of us have heard (and known people) who lived far beyond what the physicians said they would — and that seed of hope, in those cases, wouldn’t have been unfounded and the extra care wouldn’t necessarily have been wasted. For the many who still have “unfinished business” in life or aren’t yet in a financial or social position to drop everything, hope is essential.

  179. While I agree with the basic philosophy here, it seems to apply to those in the “autumn” of their lives much more so than those facing terminal situations earlier in life. This article seems to focus on those who are financially secure (at least for the most part) and perhaps have no kids or they’re empty-nesters and life is pretty well settled for them. There are many other life situations out there, of course, such as those with young kids at home and those who do not make anywhere near as much (or have been able to save as much) as physicians. What about those who have no choice but to keep working through terminal illness? What if they’re the sole or primary breadwinner for a young family with little or no savings and even though they’re not wealthy or have much in savings, they’re still doing a far cry better than their parents? I work in healthcare and the thought of having to slog through continuing to work day in and day out while my two kids (both under 5) are at home waiting for me while I spend every day knowing that I only have, say, 4 months to live, would be so incredibly and unbearably stressful that it wouldn’t be anything close to “quality of life.” Many like me don’t have the money to just quit a job, “close a practice,” or otherwise be able to just “enjoy” life and go to Disneyworld/land, travel, read, etc., at-will. We would spend those last 4 months feeling guilty about doing “nothing” to try to stay alive and just “giving in” to death while feeling like they’re almost intentionally (and happily) leaving a wife or other family members to pick up the burden of raising and providing for young kids after we walk into the sunset. I think articles like this need to be qualified — it reads as though everyone out there ought to be thinking the same way. Please indicate the intended audience, because if you’re implying that everyone, in a general sense, should consider thinking this way, that is the same kind of arrogance many people find insulting about the medical community: that “everyone should think, live, spend the way I do” and that “everyone should already have the resources, comfort, perspective, knowledge, and peace in life that I do.”

  180. My Mother passed on July 6, just a few days ago. She fought the good fight, she was an insulin-dependent diabetic for over 50 years, though she never weighed over 150 pounds, even when pregnant. She had the broken hip, and bounced back. She smoked for 50 years. A few weeks ago, she went into renal failure, and lung cancer was confirmed. She made it very clear that at 75 years old, she would not consider surgery, chemo, or radiation. Dialysis was not very effective. All 5 of her sons were there as she signed the hospice papers, she went home the next day, and passed peacefully 4 days later. All 5 sons spent time with her on Saturday. She was lucid and coherent. That evening, she experienced shallow and labored breathing, and then it was done. I don’t have any tattoos, but No Code is looking pretty good. I hope my passing is as peaceful. I have medical directives and power of attorney sworn. Written across the top in black magic marker are the words “Pull the Plug!”. Please take the time to make your wishes known, and fill out the proper papers to make it easy on loved ones. It could be a car accident tomorrow.

  181. Yes, you could have put him in care, and yes, you could have ‘been there’, but think of how much reward you would have missed out on; no deed is ever wasted, and all the time, effort and money you spent looking after your father has been recorded by the One who sees and knows all. Think of it this way – when you were a child, didnt your parents spend all their time, effort and money looking after you? Didnt they stay up nights, clean your sick, race you to the hospital when you hurt yourself? Dont we owe our parents the same kindnesses, if not more? There is nothing, NOTHING, more noble than looking after a parent in their old age, and because it is an act which will get you huge rewards in your afterlife, it is also the most difficult thing to do – heaven doesnt come for free.

  182. As an RN for many years, working with many ill and dying patients, I both agree AND disagree with Dr. Murray’s theories. First of all, there is no scientific data sighted that proves that physicians do not seek advanced treatment for “terminal” illnesses. I have taken care of several physicians and do not recall one being DNR/DNI, because physician’s know that this means they will not receive full treatment. Of course, my personal observation is not scientific either. However, I do agree that in elderly, ill patients (not those in good health who happen to be diagnosed with cancer, which can be treated successfully) prolonging life, especially for the family’s benefit, is absurd. I have seen demented patients with extensive pressure ulcers undergo weeks of futile treatment, only to die in excrutiating pain. I have taken care of patients who have have serial amputations in an attempt to save a limb that is not viable. Why? Because they get paid for every surgery they perform. Money DOES play a huge role in the over treatment of patients in this country. I have had many patients whose wishes were not followed by the family when the patient can no longer make those decisions. I advise people to not assign anyone to be their agent on their advance directive because the family can and does override the patient’s wishes. And the physicians are complicit in this regard. The only medical staff who truly advocate for the patient is the nurse…and thanks, Dr. Murray, for getting your dig in about the RN who reported you for d/cing your patient’s intubation tube. I would bet there was no order to extubate your patient, which is required by law. And while I agree with your action, the RN is not to blame for doing what she had to by law. At any rate, as a cancer survivor, I believe in treatment to a point. And yet, who decides when it is futile? Who initiates the treatment, right or “wrong”? The physician! No one else has the ability to write orders for treatment. If the patient/family is not educated, they look the physician for help. However, physicians are woefully lacking in their ability to educate because most do not feel comfortable doing so. I literally have physicians hide in their office to avoid talking to a family or the patient. And at this point in my career, I give my own advice because I am often asked for it. I give it “off the record” because of course I cannot effect treatment! I have advised patients to get second opinions, or go to another physician if they do not like the care they care receiving. I advocate for my patients. It breaks my heart when I see physicians treat patients to DEATH,literally. As a much younger nurse, I was “forced” to send a comatose patient to radiation, against my better advise. I received a phone call soon after from the radiation oncology nurse asking why I sent this patient in that condition. I told her that the physician demanded it. Well, since then, I have become quite defiant. The patient comes first, not the MD.
    Fortunately at my hospital, we now have a palliative care team that assists patients and their families to make end of life decisions, and we have less problems with physicians giving false hope and futile treatment. But there are still plenty of very old, very sick and very demented patients receiving what I call the “million dollar work-up”, often NOT at the family’s request.I
    I don’t know how all of this over treatment started. It really is a chicken and egg thing. But my suspicion is that physicians came to believe that modern medicine , and by extension, the MD himself, could heal all patients of all disease and pushed this down everyone’s throats. And to an extent, this is wonderful. However, they didn’t know when to stop, and in many cases still don’t.

  183. One example does not make for universal assertions. The important thing to remember is that the decision of the amount of care needs to be made by the patient, or the patient’s representative in the event that the patient is unable to communicate, and not driven by the perceived “benefits” or “liability” of the doctor and/or hospital.

  184. @Belinda: Thank you for this insight to GMO’s. We are bullied into eating what ‘they’ tell us to eat, and not because it’s going to make us healthier..quite the opposite. What an inspiration you are! Not many believe that God still exists..let alone help us in the ‘most matter of fact way’. He is a natural healer; ( all we have to do is just ‘believe’ in him) he is a true friend when all other friends believe mainly in material things. Like you said: He is a lot more loving than he has been made out to be, and a lot more human than the Old Testament makes out, He is not there to hurt anyone…we do that on our own, it is our own fault that things go out of sync, because ‘we’ think we are in control and instead of letting Him do the work his way..instead of holding back we push things ahead..and bang we destroy the outcome. Thank you all for your worthwhile comments on here, ‘Life’ is after all so precious, and we want to hold on to it. Lets hope I shall remember to do the right thing should I need to, when the time comes.

  185. 2 years ago next month I lost a friend I had known my entire life (she was 2 days older than me and our mothers were in the hospital together when we were born) to Cancer. I visited her a number of times in her last few months along with my husband. As she lived a couple of hours away we only witnessed small bits and pieces of what she went through. She fought really hard to beat Cancer but in the end it got the best of her. A year ago next week my husband was diagnosed with Cancer. He had been ill at the beginning of the year and from the first time he went to see his Doctor in February it took until the middle of July to be told it was Cancer. Two weeks later we were told it was terminal. Right up until the day before we were told it was terminal, my husband was talking about treatment and getting better, and making plans for the things we were going to do once he got back on his feet. With the diagnosis of terminal his view on things changed. He went through so many tests before he was diagnosed, but all the tests were ordered by his Doctor, we were told that the Cancer Hospital would not even consider him as a patient until all of the tests were done so that they could evaluate him first. We did not actually hear from the Cancer Hospital until 2 weeks after my husband was diagnosed as terminal. They wanted to discuss treatment!!! My response was “for what? he’s dying”. The person who called from the hospital actually said to me “oh you don’t want to miss this opportunity!” Can you imagine someone from a hospital seeing it as an opportunity for a man who is confirmed terminal to admit himself to the care of Cancer treatment when he knows there is no hope? After witnessing what my friend went through the previous summer, my husband chose to spend the rest of his days at home with me instead of remaining in an environment where he would be poked and prodded. He did not want to try any type of treatment that would just make him sicker in the hopes of extending his life a few more weeks He chose quality not quantity. He felt that the bed he would have taken at the Cancer Hospital would be better used for someone who actually had a chance of survival. We were told he had 4 to 6 weeks, he lived for another 4 months. Except for the 2 weeks he spent in the hospital when they did surgery to put in a stent to bypass his liver, he was home up to the day he died. When he was in the hospital he was in a Palliative Unit for a few days. We discussed his decision with his Doctor, I’ve never seen such a look of kindness mixed with relief on a persons face as I did on the face of my husbands Doctor when we told him what we had decided. He did not try to sway my husband he just said “I think that is a very wise decision”

  186. My husband passed in March from an astrocytoma that went from grade 2 to 3 or 4 over the summer. He was offered another round of chemo, but refused knowing what we knew when he was first diagnosed in 2010. We both were grateful that the Doctor (s) at Cleveland Clinic were so open and direct with what he ( we) were facing. We believe the initial treatment extended is life, but also knew that God was giving us “fair warning” that He was calling Tom home, so my thought is that we can only do so much and the doctors can only do so much. We all have to be ready or at least prepare for if we are faced with a decision of life and death, how important is it to extend your life on earth if you are only existing? My husband was very blessed. He experienced no problems during his initial chem/radiation and for the most part enjoyed his last few years on earth to the fullest. Very grateful for modern medicine but when God calls us… don’t fight it!

  187. I am a nurse and both my sisters are nurses. We have had these same conversations with our parents and our spouses. I have often voiced that what we often offer people as appropriate care is abuse. An ego boost for someone to use a new procedure they know or try a new drug… but often its just physicians and nurses caught in a system that isn’t reasonable. Thank you for writing this. People need to hear this. Patients and families often think they are only doing what we as health care professionals would do because isn’t it always right to do everything possible? No it’s not. I have always said just because you can doesn’t mean you should.

  188. My Mother suffered in a Nursing Home too. There were no ‘Nursing’ administered, and you could never call it a ‘Home’!! She died a painful death, and it has never left me. I did ask the Social Services if I could have her home with me, but they denied me, saying she would need a Doctor at hand, yet when she fell ill and I wanted a doctor to see her, they said that I would have to phone him myself, which I did. the Dr. was livid, he told them that her air bed was flat and useless, and that it should be changed straight away. I could write a book. The pain that a family has to go through when all you want for your mother is to have her treated like she would be at home, nothing more, but that never happens in a ‘Home’. Sadly.

    I, too, suffer with Fibro. and find some days more difficult than others. Mornings are worse to get out of bed, I haven’t slept more than about 20 mins at a time for years, so I listen to the radio till morning comes, but at least my body is resting. When I’m feeling ‘good’ I will try and do lots in my large garden…which is busy growing to look overgrown! I used to be able to cut down the leylandii; carry bags of cement; do cementing jobs about the place, lay crazy paving slabs down the garden path; Paint the ceilings; Wall papering, and lots of heavy stuff…(not bad for a woman!) Someone said that lack of sleep can bring on Fibro. I am now 71, but a doctor cheered me up when he said the he couldn’t believe I was 60!! (and the rest..I thought to myself!) I do eat a lot of salads which make me feel ‘healthy’, but as I am only a small frame 7 and a half stone, I don’t want to lose weight, in fact I’m trying to put it on.

  189. The scenario described in this blog happened to a good friend of ours. He was 85, and diabetic. He developed blood clots in one leg. His doctor insisted doing a procedure with a balloon in an effort to increase circulation. Not only did it not work, it made his leg worse. Gangrene set in. I remember going to visit him in the hospital and realising he had gangrene. By the time the doctor decided it was serious enough to amputate, the gangrene had spread. I am a layperson, and even to my eyes and brain they took far too long. A few days later they came to tell him that the gangrene had spread to the other leg and they would have to take that too. He refused – and he just curled up in his bed and was gone within four days. He spent a month in the hospital, mostly in pain. His daughter, a surgical nurse, said that if he had not had any of the procedures done the chances were he would have lived another two or three years in a minimum of pain. As a clergy and hospital chaplain, I am always struck by how many very elderly people are having major surgical procedures from which they never recover. I am struck by how many families’ wishes are over-ridden, and have counselled families that they are entitled to call a family meeting with all the medical staff present, and *tell* the doctors what is and is not going to happen. In at least two cases it not only relieved the patient’s fears but also the family’s.

    It begs the question though – why are people so afraid of death, and why are physicians so afraid of telling the truth?

  190. teri … well stated, as a current RN, I also think Jack was a hero, and mt family understands I am to be a DNR …

  191. Just to keep it short,I agree it is a horrible thing for Doctors to keep treating a patient when they know at best, it would only extend their life a short time and they would be miserably sick until they die. I also can see why in some circumstances, Doctors feel pressure from the family to do all they can. Then there is the case of the Grandmother mentioned earlier that received treatment for cancer and it worked and she is now living a full life at 80 years old.(or should I say 81 as this is over a year old)
    I feel that first and foremost we should all have a Doctor we can really trust, the next thing is, we should all have a living will so our loved ones don’t have to struggle over what decisions to make about our lives. Last but not least, by combining these two things when the time comes,we can ask the Dr.( that we trust) what are the chances of our loved one pulling out of this, and then make an informed decision based on the information the Dr. has provided. They are not always right, but they have seen more situations like this than we will ever see.If it is a situation that is hard to decide then we need to pray for guidance for those of us that believe in God. I started having strokes at age 44 because I have a bleeding disorder. I told my son that I did not want to be kept alive if I cannot take care of myself, also no feeding tubes if the Dr. says it is not reasonable to expect me to pull out of it. I am age 59 now, I surprised everyone, I am still here, Thanks to God most of all, but also to my Dr. Dr. Kerry Friezen Chattanooga Tn. I wish everyone that reads this would also think more about what they are putting in our foods and how they are genetically modifying our fruits, vegetables and grains. I know everyone has been hearing about gluten free foods. Did you know that the GMO’s are what’s causing it. no telling what is going to pop up next because they are doing this. It was indirectly one of the contributing factors causing my strokes because my intestines could not absorb vitamins and nutrients making it easier for me to have bleeds internally. If you can ,eat more fruits and veggies and lean meats. (we all already know this), but make them organic and not genetically modified.I know they said that organic was no better for us than regular produce, and that is a true statement, however ,what they didn’t say is that it is the pesticides that make it bad for us, not the produce itself. Morons!!! That is what we should be more concerned with, because we have to eat to live. The most important though is to please find God and get to know him through his word. He is allot more loving than he has been made out to be, and learn about how when he created humans and the earth and animals, he never intended for things to be like this. Someday he will restore it and us to the way it was suppose to be. ok, I know, it was not short like I intended.

  192. This is a really good thread. Sorry for my jabber but I want to share, many of us know of the need to adjust our Operating System to reflect knowledge gained since it was written so long ago.

    Looking from a scientific viewpoint a human mammal shedding its body is normal, natural and necessary. Life to be defined as a part Free Energy, part Mass Energy and the last part is the true mystery of life, Memory Energy.

    We humans don’t seem much in a jovial mood when it comes from another human shedding their flesh. We are idiots in this stage of our evolution, we have wars and keep cute barnyard mammals in pens ready for the slaughter or robbery of bodily fluids. We are human mammals and from the looks of our dimension right now, I’d say that yeah, we are idiots.

    The good news is that the sum of eternity is in the equation for the possibilities of Life in this here universe. I think that we have to go through the shit to get the basic knowledge, pleasures and displeasure’s of being q mammal who is sailing around a large nuclear furnace and we keep careful track of how many orbits we have gone so we can give them our age? See, idiots. LOL Quick build some monuments to Nikola Tesla. Just great being a mammal, eh? Think that human is the height of life during eternity?

    Good thread

  193. Couldn’t agree more on the perspectives of quality of life. One important rule of medical profession is not to be judgemental and provide all options (even though some are extraordinarily dire). This also include consideration of cultural differences and social perspectives of life. Pain and suffering can be a much more desirable options than death in certain cultures. Even the dimmest hope can push the individual patient to go through the toughest chance of survival. With the advancement of intensive care, the dim chance of survival can be the pivot point where families and patients cling strongly onto. As a lay man, it will be difficult to understand the difference in mortality between 10% and 30% comparing different treatment regimes. The challenges medical profession faces with terminal illness will become more complex as the line between quality of life and death is becoming more of a variable moving target.

  194. binky makes an excellent point. Being at home is everyone’s hope, made more appealing in movies and TV than in real life. Years ago when there were no alternatives, that was commonplace. But so were many other practices that are no longer part of our experience, like washing and preparing the body afterward, “laying her out” for the wake, etc.
    The ideal modern setting for death is a residential hospice.

  195. Thank you Dave and Mr. Ballard for your posts. Dave, I am so sorry for your loss.
    My youngest sister had similar DNR documentation, yet, she was “brought back to life” twice. Watching her on life support for four days was agonizing. When her husband and daughter decided to disconnect life support she officially died two hours later.
    Will having the “DNR” or “No Code” tattoo really insure that your wishes are respected?
    Thank you.

  196. “Just” taking her home to die is no easy thing either. My dad died of lung cancer at home as that was his wish, but it took 4 of us doing shifts to give 24-hr care, along with support from local hospital etc. All 4 of us spent all our time caring for him, i was mostly moving furniture (making a bedroom in the dining room) that we hardly had time to talk to him. Meanwhile half an hr drive away is a hospice where he would have been nursed and we could have simply “been there”.
    I know its little help to say that after your dreadful experience. I’m really sorry that you went through that.

  197. I am a retired RN/Medical Case manager who started my career as a Paramedic. I worked on the Oncology/Renal/Respiratory floor while I was going through school and I have worked as a Hospice nurse. I will tell you that:
    1) Jack Kevorkian was a hero. 2) ER/Trauma nurses joke about it (I worked in a Level 1 Trauma unit after graduation) but it’s true….we would all like to get a “DNR” tattoo on our chests…and I DON’T mean “Department of Natural Resources.”

    And I have also been a cancer patient. I was lucky in that surgery and radiation was all I needed because chemo is not for me….

  198. I was a Hemodynamics Technologist and on a trauma/emergency team. I was responsible for some of the special lines and tubes in the critical care setting. One day after participating in a hour and half long code blue, the patient finally became steady with a normal heart rhythm. At the desk, filling out the note sheet I remarked to the physician in charge of the code that he did a good job. He said, “thanks… too bad she’ll be dead by tomorrow.” So I asked him why we had just gone through all of what we had just done… an hour and a half of intensive activity. He said, “because we can.”

  199. I am a doctor, working in the field of Emergency Medicine in Portugal.
    I am not familiar with the US health system to a point where I can gauge patient’s and doctor’s motivations, but I can tell you that our system is rather different from what is described here.
    Certainly there is the same kind of family pressure to “do everything” some times, but I never felt as pressured as is described here to provide excessive care.

    As a disclaimer, let me state that I myself have suffered a cardiac arrest while working at the ER and was one of the lucky survivors, but I had just turned 50 so I think it was a good bet. Hopefully I will be here for a long time, taking care of patients, but that still didn’t change my view of the issue.

    I believe that what I like to call dysthanasia is not something healthcare systems should provide, but sometimes it’s not easy to decide what is and is not excessive. In the end it is mostly up to the healthcare team’s common sense and the amount of peer pressure they are exposed to.

    Over here, as I stated above, we don’t feel the kind of pressure that seems to be implied in the article, I and I am convinced that is due to the much lower level of court litigation over health care we have here and maybe also cultural differences, where portuguese people live comfortably with fate. We even have a musical genre focused on it, it’s called “fado”.
    I have to make that kind of decision almost every day and I usually speak openly with the family, but remain firm on my decision to not provide excessive care, but sometimes it’s a very tough decision and when in doubt…

  200. I too agree that we should have the right to decide if we want to live or not when the quality of life is gone. Personally I treat myself these days – cannot trust the system to do right by me & I dont care to be over treated.

    After being shunted around so much for my thyroid problems, I started to research extensively online & started being my own doctor.

    For all of you needing medicines and supplements without prescriptions & for self treatment outside of the system check out this site –
    http://www.iherb.com?rcode=adi101

    You will get $10 off your first purchase. You can also get free shipping via UPS + Zero Tax for orders over $80.00! Free 1-3 Day shipping + Zero Tax for orders over $40.00!

  201. I’ve done cancer-chemo. In support-group, I learned that the treatment caused horrible quality of life for a slight (if you believe true) increase in life-span. I am a born-again vegan and refuse cancer-testing. I am physically active. And doctors have probably seen the worst and should know the truth.

  202. What a tragedy.
    I read about a physician who had DO NOT RESUSCITATE tattooed on his chest to prevent such mistakes.
    I hope those who believe doctors favor minimal treatment are paying attention.

  203. My mother went through the painful end of life treatment “rescues”. Even after repeated multi-person meetings with the director of the care facility that included notarized documentation of the DNR “care” went awry. Since theh copies provided to the site manager were in her confidential file cabinet, the document was not available when mom’s trauma occurred after midnight. The over-night staff could not produce a DNR, so the ambulance hauled the poor woman to the hospital for days of heroic and costly tests. My heart aches to this day. This did not happen once but on multiple occasions. The hospital staff/management chose not to rely upon DNR documents that accumulated in their files.

  204. The best way to drastically reduce suicide among an ignorant mammal population would be to think before we create a baby, ask is our world a good place to bring children?

    By the time our children reach puberty they learn they were brought into a hell hole of ignorance and insanity? Rather than using our energy to help create a good, safe and fun world we use our energy and other resources to get laid. As if that i’s a goal of life to do so. Sex sells but physical sex is for 1 purpose and that is to have children, emotional love is real love, the physical is masturbation unless you are making a baby.

    If old fogies, those who cannot wipe or care for themselves knew when it was time to leave, understood that it was necessary to leave, this sailing hunk of space compost that we orbit our center star from, this planet would contain a more youthful human mammal population. Consequently this dimension would be better for all life.

    We human mammals do not yet have the intelligence to make a good world for our children. The human population are blood related, there are no exceptions yet we make borders and have wars. War is insane.

    Is their a way to edit our posts after we his Save? lol

  205. Mr. Kelly, it’s best you and I agree to disagree. I am as opposed to suicide as you. As in the case of abortion, another inflammatory life and death issue, I consider suicide morally reprehensible. But I have read, seen and discovered over time that this is one of those inflammatory issues that generate more conflict than reconciliation. That seems to be the case when those with strong moral convictions, single-issue advocates in particular, seek to make their views normative for everyone, even if it means distorting suspected motives of opponents or enacting laws that would make their choices normative for all. If you have any disagreement with me it is because I support the option of allowing choice in a circumstance that you are prepared to deny, As you said, efforts to legally protect that choice were successfully “defeated in Massachusetts.”

    At the risk of being repetitious, it appears that those who would make individual beliefs normative for everyone are fortunately a small and shrinking minority. As social norms change to allow more differences of belief and opinion (some call it freedom while others call it sin) the number of life choices multiplies.

    It is important not to confuse “choices” or “options” with mandates, especially when those choices affect no one but the individual involved. Yes, I am sensitive to the secondary impact on others — family and friends, lawyers, probate investigators, politicians, clerics, etc.– but in the final analysis, the only “victim” is the individual making the choice.

    I am not your garden-variety Liberal, glibly prating about this or that cause. I have been in this camp for a long time. Even before being drafted as a conscientious objector and serving two years as an Army medic, I was part of the civil rights movement before the Civil Rights Act of 1964 was enacted. My feelings about people being free to have choices run very deep. I am quite sensitive to the challenges faced by disabled people and even now my post-retirement work as a non-medical caregiver has broadened my appreciation of their challenges. My assignments have included more old people than younger ones, but younger people with brain injuries or other challenges that will be with them for the rest of their life have also been part of my experience. It has been my observation that family and friends (and I might add well-meaning activists) often generate more problems than professionals.

    As I said, we should probably agree to disagree about end of life issues. I am adamantly pro-choice in this matter and am not likely to change my mind. Even now, years later, the memory of Terry Schiavo still haunts me. Here are some thoughts I had at the time of her death in 2005.

    http://hootsbuddy.blogspot.com/2005/03/martyrdom-of-terri-schiavo.html

    I haven’t checked the links lately. Some may no longer work. But the core of what I wrote has not changed. And neither has my position, which is that end of life and beginning of life issues are intensely private and personal and there is no good place for uninvited outsiders to intervene, no matter how good their intentions may be. Families have enough to worry about without consulting the whole US Congress and president, There is quite enough criminal activity without adding optional end of life decisions to the list.

  206. My medical ethics course a decade or more ago presented the results of a survey: Doctors significantly underestimate the quality of life of their patients compared to the actual quality of life endorsed by those similarly surveyed patients. It makes sense that a physician might wish to avoid progressive disability, but that physician also fails to account for the “new normal” that happens after a change in health or function, and that just giving up and dying is not always a desirable course. Not all “heroic care” is without value. And it is impossible to generalize about the appropriateness (or lack thereof) of care in every situation.

  207. It’s true that people with disabilities are vulnerable. Having said that, when there comes a point where the individual is rotating between hospital and rehab with similar presentations, the quality of life has already declined by then. In a situation like this, at times, goals of care/end of life discussions can become challenging, especially so when they become unrealistic.

  208. John Ballard, that’s quite a bit of liberal dander you’ve got up there, but I’m actually a disability rights activist, and often find myself tangling with Liberals like yourself. Like most disability rights activists, I am a progressive and am proud to oppose assisted suicide– for social justice reasons! – alongside medical organizations and palliative care specialists (and religious conservatives).

    As such, I am very concerned about the general push to minimize treatment. Disabled people face the opposite problem, of not receiving the treatment we want and deserve. And when doctors, such as the author of this piece, start talking about what is “reasonable,” disabled people know what is coming. Many of us have to fight for treatment, against Doctor wishes.

    And yes, suicide statistics do track with both class and race. Check out how many black people have committed assisted suicide in Oregon, or how many Latinos. Promoters themselves talk about the higher educational level of the assisted suicides, as if higher social classes make better decisions.

    I hope that I could persuade you that medical treatment at the end of life is not just a medical issue but a social one, in which quality-of-life judgments are constantly being made but not discussed. And perhaps you would come to see that discrimination is inevitable when some people’s lives are valued less than others, and there is lots of money to be saved.

    That’s how we defeated assisted suicide in Massachusetts, a very progressive states by American standards, by persuading enough liberal-minded people that assisted suicide is discriminatory anddangerous. I encourage you to inform yourself about the disability perspective!

  209. My mother was a nurse. She received radiation for breast cancer fifty-five years ago. At that time she had a one percent chance of survival. It added fifty years to her life. In the end she suffered from emphysema and recurring cancer. It seems everyone in the medical profession chooses to avoid the long process of futile care. Hospice sounds similar to what we call palliative care in Canada. My mom died peacefully at home. I have ensured that my wishes are well documented and I choose not to run up the exorbitant medical bill. Quality of life far surpasses quantity. Mom’s last year was a lot of fun.

  210. Mr. Kelly, I see from the link that you are a single-issue commentator so I have no intention of trying to change your narrow mind. But for the record and other readers I need to leave a two-part reply.

    First, Oregon, Washington and Vermont already have legalized physician-assisted suicide and others are certain to follow. End of life issues, like beginning of life, are no one’s business but that of the individual and their families, and whatever legal, medical or spiritual resources they choose to include. Thus far the Supreme Court has not seen fit to federalize either matter. (Roe vs Wade set out guidelines but made it clear that the legal question, like that of marriage equality, is not a federal matter. Same applies to end of life issues,) Those who would make their individual beliefs normative for everyone are fortunately in a small and shrinking minority as it should be. I’m not optimistic that you will, but you might want to see the issue from a different point of view.

    Second, I lost a high school classmate to suicide a year or so ago. He lived in Oregon where the “cocktail” was available but according to his son, used a gun instead. He had been diagnosed with terminal cancer and made the choice himself, but only after putting his affairs in order and making arrangements for his widow. The legalization of assisted suicide thus far has had no impact on the statistics of suicide where it has been made legal. Socio-economic classes have little or nothing to do with suicides, assisted or not. I’m not an expert but I would say occupational groups have little to do with it as well.

    I have been a regular reader of posts and comments at this blog for years and your comment may be among the most ill-informed I have come across.

  211. The missing piece here is that doctors are also members of an upper middle-class, very well educated, secular population that values control very highly. This is the social class pushing for minimal treatment and legalized assisted suicide, in part because it cannot face the prospect of being cared for by others.

  212. Studies show a high raw diet or all raw diet reduce fibromyalia symptoms. My friend starting eat mostly raw food, no wheat products and had 2 glasses of freshly juiced vegetable and apple juice. She lost 8 kg and lost a lot of her symptoms. She feels less tiredness and can now walk for half an hour each day which she hasn’t been able to do for years.

  213. Although I agree with the premise and have a living will for myself, each situation is different and each person is different. There’s not one size fits all.. When mom was 96 she was diagnosed with lymphoma in her nasal pharynx . She had surgery, but it grew back. She had another surgery and the doctor recommended chemo. She said no because of her age, but he said, “you will die a horrible death,” suffocating to death. She went for chemo and then radiation. It had metastasized into the skull bone, but they got it all. She lived to be nearly 102 and died in her retirement home apartment getting ready to go down for lunch. Her last decade was difficult, but she saw me remarry after 19 years alone, my brother remarry, me graduate from college finally, my son graduate from college, got to meet her great granddaughter (five different times) and great-grandson on Skype from Alaska. I wonder what mom would say.

  214. This is a very interesting and touching story. One thing that stood out to me was the story Kens brother Torch. Reading it seemed really positive, and like it was the best possible outcome for the situation…however I found myself wondering, could I have made that decision in his position? Although the amount of treatment he discussed sounded horrible, I think that most patients have this idea of an against odds comeback, and that they can beat it. I think that I would. I guess I get most of those ideas from reading Lance Armstrongs books, and how all of his doctors basically said he was going to die, yet he beat it. I think if a variety of doctors told me with 100 percent certainty that I would be dead in a year, then I would do as Torch decided. However, if they were to say things like 90%, 80% etc, I would tend to pause and think….well there is a chance.

    I know we are all different, and I suppose that if I did choose to get aggressive treatment in that scenario, I could very well come to regret it. But I don’t know that I could spend the last 8 months of my life wondering if I could have been cured. I think some people would make peace with that easier than I, but I know that doubt and possibility would eat me up inside.

    Either way, wonderful and insightful article Ken, and I am very sorry to hear about your brother. I am so glad that you got the time at the end to be together so much, and have the kind of find most people save for “later when I retire.”

  215. It really depends upon the doctor’s belief system , what they think about what the human calls death.

    The first time death came to me, 1969 New Orleans, Vieux Carre’ in the back of a VW microbus where when faced with the thought of death, I was scared shitless, in near panic for all night.

    Eventually I accepted giving up my body and when I did it was like a heavy link from a chain that I wear around my neck falling off.

    Once we eliminate all of the links we are free to go, not only that but wanting to be a mammal on a sailing chunk of rounding off space debris, orbiting a hot fire ball then counting the orbits so we know what age to act. That’s idiotic but that’s the way it is. Do you really think that being a mammal is that cool? Our fears are what holds us in this dimension, fear of the unknown, fear of a monster god deep frying our mammal bodies with our pain receptors always active forever. LOL I’d like to meet that pos and straighten it out.

    Don’t you think that a lot of disease are caused by intake, like we are what we ingest? Bad, harmful poison is advertised/PUSHED on the population night and day over the media often. Is it any wonder why people need healthcare?

    Burning oxygen robbing fossil fuel to generate what Tesla called free energy and putting it in our vehicles to burn and in our airplanes who are like crop dusters and we are a part of the crop. We are not intelligent mammals, quite the contrary, we be idiots.

    The average human mammal has thousands of Stop Codes placed by those who were given programming privileges when we as children were in our most vulnerable and formative stage of childhood. How about a babysitter who believes that a shot of whiskey is good then 2 shots must be twice as good?

    We temporarily reside in one hell of a character generator of life, learning values that we need in order to advance to the next logical frequency of life. If we pay attention, don’t pop a pill when troubled but work the problem out and become its master , we will be stronger and that problem will never bother us again.

    There are many problem in this dimension and if you think that kicking the ass of one problem is all there is, think again, there are a lot but each one you whip by logic and an inner strength that comes from not being afraid, those that come afterward will be easier to handle, Each beast that we disarm our minds are opened that much more. Some day you may get to the point where you say, “being a mammal sucks.”

  216. I believe an important and crucial point is missing from the article. Now please do not misunderstand the subject material is challenging and the author has done excellent work discussing the complexities.
    I though have an observation as well. I believe health care professionals also observe the circumstances by which individuals may lead a less than grateful life experience. In other words, in a world where people throw away material things without a seconds’ thought so do they toss the experience of life aside. It is in turn from the observations connected to these actions that find their way into the supports of the that health care system that health professional learn another valuable lesson. Life they realize is precious. Life, they come to see and however long, should not be wasted nor should we pass the opportunity to experience it to its fullest. In seeing and learning this they know when your time comes to wave goodbye you can do so saying its been great and thanks for the ride. Avoiding the unnecessary and futile effort of avoiding the bad to only experience the worse when what makes it good all around is what is in your hand at that very moment.

  217. I don’t know how doctors want to die but for me, I want to go out with a smile knowing that Mother Nature will have Her way. We really don’t get to lose our body all that often so it should be a positive experience. Unfortunately we are still too ignorant to accept fact and science.

    I figured that our DNA is our blueprint to each cell that we carry and with a healthy diet, no alcohol, no canned pop, coffee or cigarettes or heavy meat that’s full of chemicals we use what we ingest to replicate new parts. We replace each cell in our body on a continual basis, we even grow new brain cells.

    All I use is long grain brown rice, bean, avocado, carrot and other healthy fare, and oh, marijuana. If it’s not legal in your state as indicated, work for legalization, join NORML, go to their meetings and you’ll be taken care of or find someone from the black market for good, nutritious herb. Pot is gaining approval of the people in all states and one after the other are approving it. Facts are being discovered that make this plant look better all the time.

    The feds don’t like pot for some reason but they don’t seem to mind alcohol and other harmful poison being pushed on the people as if they were good for us.

    Think positive, Mother Nature is our best physician even if She sends us to the Next Logical Step of Life/Energy.

    Nickola Tesla was a brilliant person, read him and allow your mind to reverse your health problems and do not be afraid of no longer being a human mammal, I am sorry that you are in pain.

    In the Eighties I taped a medical fraud convention in Ahwatukee Arizona for a group of doctors where James, ‘the amazing’ Randi was one of the speakers, the group of doctors were telling of the scams that have been going on in the country and when they got to wearing copper bracelets, taking gold salts baths and such, they could not say that there were no benefits to be had, they were not quite sure and came to the conclusion that there may be benefits.

  218. I do understand some of this but I had a totally different experience when my father died. They (nurses and doctors) gave us many options and we let my father die with no hope to get any better. One has to be firm and take charge of the situation and you will get what you want!

  219. I was born in the summer of 1942, I had the usual childhood stuff, chicken pox, mumps, hives, the flu and colds. Doctors and nurses would go on call and treat patients for what ailed them. I have never liked needles but I remember in the second grade of elementary school, 1949, a doctor with me up stairs in the room where I lay, living in a development built in the late Thirties for U.S. Military and their families. we had a 3 bedroom, 1 bath apartment, my father was a U.S. marine stationed in southern California being trained to kill as efficiently as possible.

    After childhood my illnesses have been occasional colds, flu, sore throat and and in the mid seventies I developed a hemorrhoid. We found a family doctor, M.D. Physician and Surgeon, now retired, also was familiar with natural methods as he explained to me how to avoid surgery and solve the problem on my own.

    I rarely become sick, I stopped taking the pills I was given after my brain stroke in 2004, took them for 4 months which was 1 pill only, Dilantin. The side effects of Dilantin reads like a horror story and I lived them. I could not wait to quit so I made an appointment with Dr, Robert Spetzler the neurosurgeon who placed a nonferrousmagnetic titanium aneurysm clip that he designed on my brain. This was 4 months after release from my 7 week hospital stay of which I can only remember 1 of those weeks, the last one.

    I asked Dr. Spetzler point blank if I could stop taking the Dilantin and he immediately said that I could. I asked him one last question and that was, “Does hard work cause strokes?” He said, that no, hard work has nothing to do with strokes. I was then told that me having been a tobacco smoker may not have caused my stroke but it was a contributing factor. I have since learned that nicotine and caffeine both constrict our oxygen carrying blood vessels. I’m thinking, “this stuff has been pushed on the population since I was a little boy, since I was born really as if they were god’s gift to the human mammal, like they are great for us, so smart and sheik, increases our odds of looking cool and getting laid. Getting laid is another thing that is pushed on the people along with automobiles and fast cars.

    All the while marijuana is put down yet the active ingredient THC dilates the blood vessels in the mammal allowing more blood and oxygen to reach our brain and other vital organs. Last I heard a 1 hour treatment in an oxygen room was $5,000. lol

    I was made non welcome in stroke support, I was there simply to help those who were crippled and really messed up. I suggested they get rid of Dilantin which is in the Phenobarbital family and use good Marijuana. I used a lot of blue ink to make 2 page fliers showing the benefits. Dilantin destroys the users sense of taste and smell, I was down to 99 lbs and the food was tasteless and odorless to me from taking Dilantin. They really have a good restaurant and serve good food but at the time, on the pill food had no real taste.

    Had I been given a bowl of Marijuana to allow to seep into my lungs, THC not only dilates the blood vessels and breathing passages in the mammal body but makes plain food takes good, make good food tasted delicious.

    The side effects of the chemical by the name of Dilantin are real mean.

    I first started using Marijuana while living in New Orleans from 62 thru 68, I had my first joint in the French Quarter in 1967 and it has definitely changed my life for the best. I’ve been to 5 Mardi Gras as a alcohol drinker and the 6th as a pot smoker, I was even on a large float going down Canal Street throwing beads to the people and very intoxicated, Wish I hadn’t have been. At the end of the parade round another person whom I believe was also drunk, I think the whole float was, asked me who I was so I climbed down and went back to the party on Bourbon.

    I remember my last one, that’s where I had 3 lbs of really good weed and used some of it well that day. I still remember my in the crowd waking looking for someone I could turn on and did several times. In New Orleans in the Sixties if you were caught with 1 marijuana seed, that was a serious bust and the police department pursued we Flower Children to jail and cut our hair and make us wear prison clothes.

    I no longer use alcohol since the early Eighties, the six weeks I had no memory took care of the cigarettes, was stroking on my porch trying to roll a tobacco smoke and my fingers would not work well. Had I been successful the constriction of my bodily vessels may have meant the end of my human mammal body. My energy.memory pack that supports over 100 lbs of mass would have given up that mass causing me to shift to a higher frequency, a frequency I suspect that would be invisible to a slower frequency especially one that accumulates mass.

    We need education on death as according to the known laws of the physical universe, neither death or time can possibly exist, we are a herd of ignorant humans who are very temporary which is the way it should be, Being a human mammal for eternity would be like a sentence to hell. lol

    .

  220. I read The Emperor of All Maladies, a natural history of cancer, and it really opened my eyes. In that book doctor’s decisions to not treat is discussed. Most do not treat. My husband and I have discussed at length our desires to not prolong the inevitable, but we wonder what we will really do if ever faced with the choice. It seems the human will to survive is quite strong and I hope we will be able to make the right decisions.

  221. Cogent article on the insanity of excessive terminal care in our society, but I thought I’d learn more about how doctors dying with severe pain do it. It is one thing to sensibly avoid futile and costly end-of-life interventions but another to endure prolonged periods of pain. I assumed “smart” doctors had access to a stach of morphine or related drugs that enable them to die with minimal discomfort. How do such pain-ridden doctors really die?

  222. Oh I’d like to say a few more things, Myasthenia Gravis also makes me more tired than other people, sometimes I just have to lay down and not move for awhile, I don’t sleep, I just lay there, and then I can move about again. I must be sure to not leave my home for errands, appointments, and such, without taking some meds with me, and a water bottle to wash all those meds down my throat. I have damage in my lower esophagus because of all the pills I must take daily. Many trips to the Pharmacy to get refills. I also spend more money trying to make myself healthier, vitamins and more, n more time to go n buy those. And most people are not aware that Diabetes is ALSO an auto-immune disease, in which the body has attacked the pancreas and decreased or ruined the pancreas from making it’s own insulin, and so pills and or shots of insulin must be taken daily for this disease. If I ever get cancer, or my Myasthenia Gravis causes more awful problems for me, I do not want my life prolonged in any way. I have also decided to donate my body for Myasthenia Gravis research, and when they are done, they can cremate the rest of me, and give my ashes to my daughters. I hope to increase medical knowledge about MG, and so help future MG sufferers in their quest for a better life living with Myasthenia Gravis, maybe even a cure.

  223. Rod, I am glad that marijuana gave you some control over your pain. I wish I lived in a State which at least has Medicinal Marijuana, but I don’t. I think I could really get rid of some of the many pills I must take each day, 4 X/day, to be able to tolerate life and chronic pain, my spine/discs are herniated/torn in many different places upper neck to sacrum, w/ some spinal stenosis in lower back. My upper neck is the worst pain for me, the most damaged, by several cars wrecking into me-none my fault-over the years, and from 3 head traumas at work, as an Operating Room RN, the last one hit the top of my head w/ instant numbness of back of head and down my back. I have seen enough surgeries, and hear from many that they had surgery and are no better, or are worse than before, so I will never have surgery on any of my spine! I also have Fibromyalgia, with increased overall nerve and muscle pain, more meds, and just to make things worse, and add even more meds, I have Myasthenia Gravis in my head and body, it’s a neuro-muscular, auto-immune disease. So I have to take immunosuppressants which cause my immune system to be weakened as the meds try to prevent my body from attacking and messing up my muscles so my nerves cannot speak to them and tell them what to do. So I tend to get sick more often, mostly for 3-4 weeks at a time. And more meds to flood my nerves with lotsa Acetylcholine so my muscles will sometimes work as I want them to, but I deal w/ droopy eyes and face on 1 side or the other, and painful cramps in hands n legs/feet, more so when I am trying to get lovely to go out, are stressed out, or did more activity that day than usual. I take more meds at 1 time than most people take in 1 day, or 1 week! I know I would be able to control my pain and suffering if I had access to Medicinal Marijuana, and be able to decrease or discontinue some of all those expensive meds, but the Lawmakers will not listen to all those people who are happier, more productive, using fewer pills daily, in less pain n suffering using Marijuana, which comes in many other forms than just smoking it, like pills, cookies, n other ways to consume it, not smoke it. They want to keep our Pharmaceutical Companies busy and making lotsa money n make us all poorer, pharmacies busy and full, pharmacists jobs, prisons overflowing, have more people for our Police to investigate and arrest, more court cases, so there will continue to be many jobs for these kinds of people. And using hemp for so many things would save our trees, our forests, but there are too many things to use hemp for to talk about here, except homes, cars, car fuel, paper, n clothes, to name a few. So I am glad you are able to use Marijuana to ease your suffering, and I hope that soon the entire USA would also be able to do so, thank you very much for talking about Marijuana helping you.

  224. After having had an aneurysm in the base of my brain in 2004, after 6 weeks I still had no memory and wife was told to find a nursing home for my 99 lb carcass. After all I went through, none of it painful really, I think that being a human mammal sucks , if that’s all there is then let’s keep dancing, Two things, if being a mammal on a sailing space rock is the zenith of life, I feel sorry for us. If anything in the universe would like to be worshiped by anything, I wouldn’t even let it kiss my ass, I am allergic to cooties.

  225. I found this to be a fabulous article about our healthcare today. Having been the patient wanting to live and thankfully being aware of the delicate balance of medical intervention with quality of life, I am now a 10+ year survivor of ovarian cancer. Dr. Murray has captured all that I have witnessed working at a gynecologic oncology practice in a patient support position. I too have witnessed the significant difference in quality of life given the option of hope with medical intervention. Our public has a misunderstanding of medical intervention. Most believe medical practitioners will always extend life and even cure the patient of their ailment. Most trust their medical practitioner will be making the most favorable choice of medical intervention with the patients’ quality of life being of primary concern. Before we make decisions regarding medical treatment, we must do a reality check and remember healthcare is a business.

  226. Linda, I am sorry to hear about your mother. Decisions about end of life care are something that need to be made in advance, with a clear mind. It is completely unfortunate that you felt like you were not in control of her care. It makes it worse if your family has not appointed a family spokesperson as POA and then there are differing opinions or arguments amongst family about how the care should proceed. But one of the four major ethical principles that is stressed in medical education today is patient autonomy, which emphasizes that patients should be informed about all the risks, benefits and alternatives of their care plan and be able to make a decision for themselves ( or their power of attorney).

  227. This is why everyone needs an advance directive for medical care, up-to-date and properly executed, with three or more designated agents, all of whom know why they are and have agreed to that responsibility.

    End of life choices are never easy, but the challenges and uncertainty can be much less than man people experience can be significantly minimized.

    I have been a senior caregiver nearly ten years now in my post-retirement life and have seen many cases where end of life problems should never have been as painful as they were. Here is a collection of links and a couple of videos I have found helpful.

    http://hootsnewplace.blogspot.com/2013/06/hcr-hospice-palliative-care-and-advance.html

  228. Who is driving this madness? When I was caring for dying parents, I didn’t think the doctors and other providers were trying to make money off of unnecessary tests and procedures, but they were so cagey when answering my family’s questions about quality of life and what the procedure would actually accomplish that I felt I had to play detective to get answers–and that’s after I got in the habit of saying flat out that we were only interested in quality of life, not extending it, and my parents had been ultra clear about their wishes concerning quality vs. quantity. I started to think the docs’ cagey behavior was due to habit, and that maybe what was driving it was patients and their families who are terrified of death–or maybe it was malpractice fears on the docs part. In any case, if you’re a doctor, PLEASE listen when a family says seriously, we’re concerned about quality not quantity of life here. It was unnecessarily stressful to have to fight the system to get my parents’ wishes respected.

  229. I look life from a temporary human mammal viewpoint. We are not the most intelligent mammal on this sailing piece of space rock but we are the most destructive.

    People talk about what they call dying and dumping our mammal mass is natural, normal and necessary then people freak out from a necessary biological function. Look at life from a scientific stance not from one that says, being a human mammal is great, what a wonderful world. lol

  230. I agree. My mom had lung cancer and wanted to live. She went through treatment and actually passed the typical 5 year. Considering the situation, she sailed through treatment. We used to go shopping after her chemo treatments. She never even lost enough of her hair to wear the wig we bought beforehand. But she didn’t really work toward changing her lifestyle. She ended up having a heart-attack. She died in intensive care 11 days after a quadruple bypass. Even thought she only got another five years, I know she would not have changed going through treatment.

  231. dont beat yourself up over not taking your mom home to die.I took my Mom home after her second heart attack her heart muscle was functioning very low and her kidneys.It was the hardest thing I ever had to do.I also worked in an I.C.U for twenty three years and still wasnt emotionally or physically able to do it.Death is a very difficult thing to watch happen so dont second guess your decision ok.Email is Jean.M.Larose@hotmail.com

  232. I also agree to disagree. My grandma had bile duct cancer and had a choice…go through chemo and radiation to possibly live just one year longer, or let herself die in less than six months. My grandma chose to extend her life as long as possible to continue seeing her 20 grandchildren grow. She also chose a new treatment which was offered to her. After the pain and suffering of the treatment, having stints inside of her, and her having the time to decide how she will divide up her belongings to her grandchildren, a miracle happened. She was cancer free. That was five years ago. She’s now almost 80 and living a happy and healthy life. If she chose otherwise, she would have never been able to meet her three great grandchildren, one of which is my daughter. I am so grateful for the medical advances which allowed this to happen and although I am not a doctor, I would do the same to allow myself to live and see my daughter grow.

  233. Robert, see my note to Mark above.
    For some reason this post has lost track of over a hundred and fifty comments which would inform you better. It may seem a “false equivalence” but the point is far more important and compelling than the technicalities of logic and rhetoric.
    I hope the administrator and/or moderators soon correct this problem.

  234. This article begins by making a false equivalence between a fully conscious patient who has discovered he has cancer after some tests and has time to consider the possibilities and someone who has been brought unconscious into an emergency room and the sudden need for decisions is offloaded to a near relative.

  235. @Mark, I’m sure you didn’t notice but this post is almost a year old. It was published in August last year. And the comments thread — which until recently was one of the longest this blog has ever collected — just passed 170, many of which were long, thoughtful and overwhelmingly in agreement with the message that doctors do not, indeed, go “whole hog” at the end but do exactly the opposite, knowing the price to be paid for a few more days, weeks or months of life.

    They may well have sold the whole system their whole professional lives, but when their time comes they don’t buy into it themselves. That was the main point. And that point was underscored many times by commentators in the lost comments.

    Perhaps the people in charge of IT at The Health Care Blog will find a way to restore those comments. They are not only instructive, even those who want to argue, but informative as well. Many were written by medical and other professionals and family members personally involved with end-of-life experiences.

  236. Ken Murray, MD Your reporting of your cousin is very important! My Mum, my dearest person in the world to me was lost in the same manner. Yet…in a different approach. We were given hope , radiation, chemotherapy and lies! We were desperate! Only to find out her year of Hell was wasted from a year we could have spent with her being alive and happy days. When I found out the lies about her condition after she was gone I was sickened and we had failed her in life and in death. The world has not been the same. She was a test subject of sorts in the worst way. Even though she would leave us in the same time line…she was lost in medical Hell and not with the embrace of love and joy that would have made Her passing more of a transition. There would be more days of Joy! More days of Comfort! Mores days of Faith. More days of Love. Instead we were inundated with poison for absolutely no reason. After Her passing I was awakened to the reality that the treatments were garbage because of the cancer She had. I lost my Mum in 1997. It was her and my Dad’s birthday yesterday. Why are we taking away what life that is left? Why hurt the hurting. Why give false hope? Please explain why the rest of the population is not given the same respect your cousin was.
    Thank you Tianne Tucker

  237. While I don’t disagree that end-of-life care in our health system (and indeed, the whole health system itself) is severely screwed up, the opinion of you and your friend that most doctors would choose to “go gently” does not a statistic make. I’d like to see some survey numbers on this. I bet the majority of doctors actually (and perhaps foolishly) go whole hog at the end. How could they not? They have bought into this system their whole lives. If they seriously don’t think it works, they have much bigger moral issues to face than just wether to write a living will or not.

  238. Can anyone show or tell me how energy can be destroyed? Like being a mammal on a sailing space rock?

    When eternity is in the equation of life, the possibilities are unlimited. If being a human mammal is the zenith of life, boy are we screwed.

  239. You know, I agree and disagree. For all the anguish there are some who beat the cancer odds and live in remission another 10 – 15 yrs and enjoy seeing their grandchildren born and spending time with their families.

    So, before anyone decides to throw in the towel consider this: You will miss out on a lot of things. Once you make an ‘it’s over’ decision it’s final.

    I’d try to hang in there as long as possible, remember that many cancer victims die of secondary infections and not the cancer itself. So beef up your immune system, try to stay germ free for at least 2 yrs after chemo and radiation, take supplements, eat healthy, hydrate often using clean glass every time, crank up the coldness in the fridge and the hot water in the dishwasher and try to live.

    Because once you are dead, that’s it…..

  240. my dad decided not to take treatment with his lung cancer he was 77 yrs old hw lived for two more years not suffering he took ill on a Tuesday morning about twoam we brought him home on thurday and he passed on sunday he was able to visit and talk with family and friends he died like he wanted to and I will never second guess his choice it was right for him he didn’t suffer

  241. After I had accepted death in 1977, death came to me again in 88 with an abscess to my jaw, I had decided to go to my dentist Monday morning and I discovered I had the tooth ache Friday night. I needed to get through the weekend without paying a weekend rate. With 9 children to raise and support, that does not leave much for dentists.

    I tried to stand the pain but I couldn’t do it and so I started getting real hot, it was all I could do to turn a nearby fan on and aim, then fall backward into my water bed and I started feeling cold and I somehow managed to turn the fan off, fall back on the bed again placing a pillow under my feet and a blanket over me. I had already accepted no longer being a human and I had no fear at all, none,

    Soon I was floating, it was a wonderful feeling, and I knew that I was checking out as a human and onto the next logical frequency. In human terms I was dying. And it was wonderful, a truly great experience then wife is coming through the room where I was dying and I hear her exclaim, “oh, you do not look so good.” And I knew I had to get back and help her with the 9 children that she wanted that I gave her. She wanted 12 but nursing a child for several orbits is birth control.

    I am not a druggie, the last stroke related pill I have taken was in the fall of 2004, 4 months after being released from Barrow Neurological. The last cigarette I’ve had was the morning I was stroking on the front porch of my house but my fingers weren’t working so well so I gave up, good thing too as both caffeine and nicotine constrict vessels in the mammal body and that would not be good while having a stroke ingest some chemical that constricts blood vessels and such. I haven’t smoked since that day as I lucked out and was without memory for 6 weeks and when my memory made the connection, I no longer wanted a cigarette. It’s been since the Eighties since I’ve drank alcohol, that stuff is pushed on the population as if it’s a gods gift to the human mammal and it’s a toxic poison,

    I am lightweight on caffeine as well. I haven’t had cow in a decade I eat brown rice or black rice and bean, things that if you plant them will grow. Egg noodles will not grow.

    During this entire ordeal I had no pills of any sort, I am not a pill person, I had nothing for the pain other than some marijuana which gave me some control.

  242. The term Death is not defined. If life is energy, memory is energy and even our mass is energy, it does not nor can it Die. That would be a trick. Flesh can be separated from raw energy but memory energy is intertwined with free energy.

    I doubt if anything in the universe during this here eternity has ever died nor could it. We just shift to a frequency that is above mammal. No longer dragging around a pos body of a mammal everywhere you go.

    In fact being a mammal can be an exciting adventure but we should always be willing to shed our meat. I had a bout with losing my physical mammal body in May of 1969 and I was afraid, I was near panic, pulling hunks of beard from my face while driving a 1969 VW Kombi Bus from New Orleans to Phoenix.

    Then 7 orbits later I decided to accept laying my body down, no longer having control and rather than me croaking I saw the light, the light was me. For at least 2 weeks I glowed with this new inner substance. Boiled down to cut this short, the object of life is to live but the manner you live determines your future. When all hate and anger is removed from our being, we are free to go to the Next Logical Frequency, above mammal, we be free, free at last and with those who have graduated previously from our family thread of light that goes to the source, the center. God is a title for the very first byte of memory ever, the title of god goes to Her. Of course god is female, 99 percent,

    I had an aneurysm in the basilar region of my brain in the summer of 2004, I was hospitalized for 7 weeks, 6 without memory.

    Accept the natural and the necessary, help create a younger world, when prime is passed, discover the next logical step of energy.memory. It is necessary that we each dump our mass, it is essential to life that we do. I was born in 42. Oh, humans are not the most intelligent mammal on the planet but is number 1 in planetary damage.

    Enjoy orbiting a large fire ball and don’t forget to count your orbits or you will not know what age to act. Yeah, I know, it’s great be in a herd of human mammals, Hee.Haw

  243. My mother went through months of pain and suffering even after she was diagnosed as terminally ill with inoperable lung cancer. She was removed from a local hospital and sent to a nursing home 40 miles away that was too far away from friends and family to allow for visits on a daily basis. Family was given several different versions of outcome, and the promised “comfort care” was a farce. She had no choices, no TV, a breathing tube and feeding tube. She was abused by staff. She developed MRSA and had wide open skin ulcers. Finally, she slipped into a coma and was sent to a hospital — again, too far away for most of her family to visit. The hospital personnel refused to admit that she was in a coma, and a doctor called me saying she had agreed to surgery. All previous doctors had told me that she could not survive surgery. This was the most horrible situation. I learned that death, the end of life, is not anything like what you would think. You have no control of anything. The system has you. There is little if any dignity if you and your family have little money. I look back, and would have fought the nurses who told me I could not take her home. I would have taken her home against the advice of the doctors and hospital staff. I now have my own living will and have discussed with my family my wishes in case of a terminal illness. I will never submit to a feeding tube and breathalizer. I hope my family will take me home and get hospice help for me. It may seem difficult in the short term, but it is better for the family in the long term, I think. I feel so bad that I didn’t just take my mom home and let her die with all her family around. The nurses at the hospital talked me out of it.

  244. 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.

  245. 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.

  246. 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.

  247. 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.

  248. 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

  249. 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.

  250. 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.

  251. 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.

  252. 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.

  253. 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. .

  254. 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.

  255. 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?

  256. 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,

  257. 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.

  258. 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.

  259. 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.

  260. 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.

  261. 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.

  262. 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.

  263. 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.

  264. 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???

  265. 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.

  266. 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:

    http://ireneogrizek.ca/2012/12/28/5762-the-right-to-choose-life-or-death/

  267. 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!

  268. 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.

  269. Kelli,
    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…

  270. 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.

  271. 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.

  272. 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.

  273. 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.

  274. 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.

  275. 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.

  276. 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.

  277. 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?

  278. 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.

  279. 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.”

    http://www.guardian.co.uk/crosswords/2013/jan/11/crossword-araucaria-reveals-dying-cancer

  280. 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?

  281. 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.

    Goodluck.

  282. Take a look at OKtoDie.com

    “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.

  283. 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.

  284. 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.

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

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

  286. 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

  287. 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.

  288. 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.

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

  290. 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.

  291. 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

  292. 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.

  293. 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.

  294. 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.

  295. 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!

  296. 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!

  297. kelli:
    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!

    karen

  298. 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.

  299. 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.

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

  301. 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?

  302. 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?

  303. 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.

  304. 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 . . . .

  305. 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.

  306. 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!”

    Pathetic

  307. 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.

  308. 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.

  309. 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

  310. 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.

  311. 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.

  312. 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…

  313. 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.

  314. 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.

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

  316. 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.

  317. 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.

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

  319. 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.

  320. 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.

  321. 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.

  322. 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.

  323. 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.

  324. 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.

  325. 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…
    Thanks!

  326. 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.

  327. 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!!

  328. 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.

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

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

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

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

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

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

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

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

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

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

    There is absolutely NOTHING wrong with that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    God bless,

    Mihaela.

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

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

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

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

    Thanks for a thought-provoking article, Dr Murray.

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

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

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

  356. interesting article, thanks for posting. Quite depressing though 🙂

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

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

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

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

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

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

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

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

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

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

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

  364. Very moving and provocative post Dr. Murray.

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

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

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

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

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

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

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

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

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

    Just asking.

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

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

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

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

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

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

    Janie

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

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

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

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

    Steve

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

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

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

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

    Steve

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

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

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

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

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

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

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

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

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

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