Last month, an essay posted by retired physician Ken Murray called “How Doctors Die” got a huge amount of attention, some negative but mostly positive. Murray tells the story of an orthopedic surgeon who, after being diagnosed with pancreatic cancer, chose not to undergo treatment. The surgeon died some months later at home, never having set foot inside a hospital again.
Critics said that the essay was a biased opinion of how one should die, not an actual analysis of how doctors actually do die. And indeed, much of Murray’s essay was anecdotal. Murray writes that his physician friends wear medallions with DNR, or Do Not Resuscitate, orders. They instruct their colleagues to not take any heroic measures and to keep them out of the ICU at the end of life. He’s even seen a colleague with a DNR tattoo, something I’ve been threatening to get for a long time.
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And yet, there is good evidence that physicians have thought out end-of-life issues more thoroughly than laypeople and are more likely to decline medical intervention. For example, they sign advance directives far more often than the rest of us do. Less than half of severely or terminally ill patients have an advance directive in their medical records. These are legal documents that indicate the kind of medical care we prefer at the end of life and where we would like to spend our last few days or weeks. Contrast that to a study published a few years back that found 64% of doctors surveyed had signed such documents. Those who had were nearly three and a half times more likely to refuse rescue care, like CPR, compared with doctors who had not signed an advance directive.
Why would doctors be so anxious to avoid the very procedures they deliver to their patients every day? For one thing, they know firsthand that these procedures are most often futile when performed on a frail, elderly, chronically ill person. Only about 8% of people who go into cardiac arrest outside of the hospital are revived by CPR. Even when your heart stops in the hospital, you have only a 19% chance of surviving. That’s a far cry from the way these procedures are portrayed on TV, where practically everybody survives having his heart shocked and undergoing CPR.
Doctors also know that undergoing heroic measures is a lousy way to die. They’ve seen what it’s like for an elderly patient to end up in the ICU, hooked up to machines, often semiparalyzed, in pain, lying on what philosopher Sidney Hook called “mattress graves” during his own terminal illness. At a recent meeting I attended, one emergency physician tearfully admitted she didn’t think she could stand to hear the sound of ribs breaking as she perform CPR on yet another elderly patient who almost certainly would not survive.
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I know I want to avoid such a death. Not everybody feels the same, however, and whichever you prefer — “do everything” heroic measures or avoiding the hospital in the last few weeks or months of life — one of the first steps you should take to increase the chances you get what you want is ask your doctor about an advance directive or get one from the Web. Some of the most informative forms can be found at Physician Orders for Life Sustaining Treatment Paradigm.
The next step is to look at the Dartmouth Atlas, which has compiled a recent report on how different hospitals tend to treat patients in the last months of life. If I have a choice, I’ll choose to go to a hospital that’s less aggressive.
Finally, one day I hope patients will have access to the work of a brilliant and caring physician named Angelo Volandes. Volandes is developing a series of videos to help patients and families understand exactly what’s involved in many of the procedures that are done on dying patients, including CPR, being put on a ventilator and having a feeding tube inserted. He wants to give patients a chance to understand what their doctors already know.