Answer: When they're dying.
Saw this piece via Tyler Cowen @
Marginal Revolution. It is both thought provoking and beautiful. The site that hosts this article has been experiencing slow response times, so I'm going to excerpt a large chunk. But please
go read it yourself, if you are able.
It's called
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.
...
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 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.
Read the rest
here.
I have a close friend who is a doctor. For a while we were roommates while he worked at a local hospital. He was deeply frustrated by the expensive and pointless medical procedures that they routinely performed on the terminally ill and the dying elderly. These people typically had very poor prognoses. Hundreds of thousands would be spent on procedures that would extend their lives by a few months at most. And that short time would be spent in a hospital bed with tubes routing vital functions through machinery. Then they would die anyway. "Futile care" indeed.
I don't know if it's really the case, but my friend felt that these expensive and ultimately pointless procedures were responsible for a big chunk of the rising costs of medical care.
I imagine that very few people want to spend their final weeks or months eating through a tube. So why do they choose things like this for their loved ones? The author offers up a few possible reasons. I think that part of the answer is that death has become unpalatable to us. We want to control it or cure it, but we can't. Often we just make it worse.
During the last century, medical science plucked a lot of low-hanging fruit. It eradicated smallpox, brought down infant mortality and stopped people dying of the common flu. But there is still a lot about our own biology that we don't understand. The human body is a complex network of non-linear systems all feeding back into each other. The exact mechanisms for things like chronic pain, irritable bowel syndrome and aging continue to evade us. And that includes the mechanisms for aging and death.
But we still want to believe that there's a magic pill that can cure everything. There isn't.
How you die is a very personal choice, but that choice has become distorted by some very perverse incentives. Doctors prescribe unnecessary tests and procedures to shield themselves from malpractice suits. The burden of paying for these expensive things falls on taxpayers and the insurance companies, not the families of the dying. The incentives are all wrong. And lest you think that this is a case where incentives don't matter, here's a study that found that
people are more likely to die after payday.
There's a fine line between fatalistic acceptance of death and a race to extend life by a few days or even minutes, whatever the cost. I'm all for living a full, healthy and very long life. There are places I want to visit, languages I want to learn, experiences I want to try. But I wouldn't be able to do any of that drugged up to the eyeballs and breathing a machine. And I don't think that perspective is much different from most people.
People often suspect doctors of keeping all the best secrets for themselves. Well here's one that they really have kept: they've learned how to die. Maybe it's time to take a lesson from them.
