Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Doctors Die Differently

2/3/2015 1:50:51 PM | 8 comments

During my medical training, I participated in a paramedic ride-along. We encountered five patients in cardiac arrest that day, all of whom were elderly. Every patient arrived at the hospital with a pulse, so I considered the outing a success.
Sadly, I later learned that all five of our "saves" had died by the day's end. The news was a little tough, but I still took pride in doing my job, which was to save lives. Or so I believed at the time.

A Double Standard?

Over the years, I've often revisited that day when we cared for people in their final hours. I've wondered what I would want in their position, and truth be told, the answer wasn't broken ribs, intubation or a last gasp in the intensive care unit (ICU).
Like most physicians, I've seen far too many patients undergo painful, aggressive treatments that might (at most) extend their lives by a few days. It's certainly not the kind of care we'd choose for our loved ones or ourselves. And yet today in America, 29 percent of deaths still occur in acute care hospitals, and 29 percent of Medicare beneficiaries experience an ICU stay in the last month of life.
Which begs the question: if doctors reject heroic end-of-life measures for themselves, why do we so often take them with our patients?

Doctors: Going Down Easy

In my experience, physicians are unique not because of how much life-prolonging medical treatment they receive, but because of how little. Interestingly, for all the time and effort we spend to help our patients avoid death, physicians tend to face dying with acceptance and minimal advanced life support.
A few months ago, I ran across a fascinating study conducted by the Stanford University School of Medicine. The researchers were investigating whether doctors' personal resuscitation and organ donation preferences impacted their attitudes toward patients' advanced directives. (They did.) But what was even more striking was how universally the doctors in the study rejected aggressive life-saving measures for themselves. In fact, an overwhelming 88.3 percent of the participants said that when the chance of recovery is uncertain, they would choose "no code" or "do-not-resuscitate" orders.
While the Stanford team is perhaps the first to put numbers on the issue, many physicians have also remarked on this tendency. In his touching 2011 essay, "How Doctors Die," Ken Murray, MD, notes:

"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."

Patients: Fighting for Dignity

In a way, these findings shouldn't be surprising. Study after study shows that most people — doctors and non-doctors alike — want to die at home surrounded by their loved ones. Other attributes presented for the ideal death include having a sense of control over healthcare decisions, being without pain and trusting one's providers to make sound choices.
Contrast these desires with some current realities about death in America: In other words, research suggests that most Americans do not die the way they want to.

Roots of the Problem

So why do doctors administer so much care that they would not want for themselves? One reason may be that we are trained to recognize our success through our actions. That's probably one reason my student self considered our EMT ride-along such a success. In my relative inexperience, I saw prolonging life, no matter how briefly, as the very essence of my job. It took many years of experience before I was able to balance my duty to preserve life with my equally important duties to prevent needless suffering and preserve human dignity.
Another reason physicians continue aggressive, life-prolonging treatment is to indulge the family’s needs — sometimes at the expense of the patient’s. “Please doctor, do everything!” They tell us. As physicians, we need to remember that many people are unrealistically optimistic about the efficacy of lifesaving measures. Their experience with resuscitation is likely limited to movies and TV, where CPR is usually successful and the patient recovers immediately and fully. (Remember the scene in Jurassic Park where it works so well that the child wakes up and finishes his last sentence?) However, doctors know that in reality, only 3 percent of cardiac arrest patients return to their normal lives.
Finally, allowing patients to die can also bring up our own feelings of inadequacy. For physicians, a death on one's watch can be a very personal kind of failure. Opting for less aggressive treatment often provokes feelings of guilt or makes us wonder if we are "abandoning" our patients. At least when we are aggressive, we know we've done everything we can.

Learning New Ways to Care

So how can physicians recognize when further high-intensity care is futile and even detrimental? According Vyjeyanthi S. Periyakoil, a palliative care expert and lead author of the Stanford study, the first step is to get honest with ourselves:

“Our current default is 'doing,' but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself.”

Easier said than done, right? Changing the goals of treatment, or even broaching the subject, feels momentous. But we can make it a little bit easier (and less personal) by reaching out:

"It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier."

She goes on to note that doctors aren't trained to talk. But comfortable or not, end-of-life care is fundamentally about communication. Physicians must take the necessary time to inform patients and families about realistic outcomes and options. We must listen and be candid. And we must prepare for these conversations by familiarizing ourselves with palliative care resources in our hospitals and communities.
These conversations can be challenging, but can also be extremely rewarding and empowering for our patients. There's no doubt it's what I want for myself at my life’s end, and if it's good enough for me, who am I to deny it to others?
I hope in the near future, we can mitigate the disparity between what we want for ourselves and what we offer to our patients. Certainly, we are brave to fend off death, but sometimes we are even more courageous in allowing people to die with dignity.

[Image credit: "Grandma Langford reading to her grandchildren" by State Library Victoria Collections licensed under CC BY 2.0]

organ donation is not touched upon (if so briefly)... is this intentional?
6/15/2015 9:12:32 PM

Gail Silver
Barbara, this is an outstanding article and puts into words something that I have thought about many times in the past. Why DON'T we talk to our patients about their choices when they are at the end of their lives. Maybe because it is easier to just do everything? Easier for us as physicians, at least. You have reminded me that I need to be courageous and to be willing to start the conversation. Thank you!
2/7/2015 3:31:44 PM

Anne Bruce
Barbara, your article, "Doctor's Die Differently," hit a nerve for me in several ways. As a Baby Boomer, many of us are caring for parents or siblings and this issue is top of mind. I agree with Cyndy Flores that the conversation has to continue. An article like yours impacts the overall "death with dignity" movement that's taking place in America today, not to mention "death with dignity" laws that are in progress. Thank you for this thought-provoking article. I plan to share it with a number of people.
2/5/2015 6:09:44 PM

Sarah Maurer (Perspectives Editor)
Dr. Victor, I love this article and really enjoyed working on it with you. The part about laypeople over-estimating the power of resuscitation is so true. I actually just took a wilderness first aid class and one of the instructors was talking about how it's pretty rare for CPR to magically being someone back to life. Everyone was totally shocked, of course.

On a positive note, my mom, who has lymphoma, has always said she would not pursue aggressive treatments (bone marrow transplants, etc.), and her doctors have always been totally respectful of that.
2/5/2015 12:00:18 PM

Cyndy Flores
Barbara, fascinating article. It is interesting we are ok with non-aggressive measures for ourselves but not for our patients, but the study and your thoughts on why make perfect sense. I think the more we talk about it the better compassionate care we can deliver to our patients and families. And as a former paramedic, you are a black cloud...really??? 5 full arrests in one day?? Whew!!
2/5/2015 9:44:49 AM

Jeff Bass
Thank you Barbara for your wonderful article. What you wrote is true and needs to be broadcast to the nation. The majority of people would much rather pass away in comfortable surroundings with their loved ones around them. All too often, we end up torturing chronically ill, dying people at extremely high financial and emotional cost to their families, without significantly extending or improving their lives. Frequently these futile, invasive procedures serve to kill them faster. Palliative care has been shown not only to improve the quality of life in people's final days, but sometimes even helps them to live a little longer while making much better use of our limited resources.
2/5/2015 12:43:47 AM

Jon Brummond
I love this piece! Insightful, yet not surprising in any way. I am going to share this with my family as well!
Thanks for contributing,

2/4/2015 9:10:46 AM

Kevin Riggs
Dr Victor thank you for your perspective!
2/4/2015 8:28:33 AM