How do doctors prefer to die? This question was addressed in a recent article on the Website zocalopublicsquare.org. The article suggests that physicians eschew extraordinary measures to extend life; instead they put a priority on reducing the pain and maximizing the quality of any limited time remaining. In a discussion on Medscape Physician Connect, an all-physician discussion group, doctors evaluated the accuracy of this portrait.
Overwhelmingly, the respondents agreed with sentiments expressed in the article. They sought to avoid the agony of a lingering final illness for themselves and for those they love. The results of an accompanying poll were unanimous. When completing the thought, “If I or my family were faced with a terminal illness with great potential for a terrible course and reasonable options have failed,” all 27 respondents chose, “I’d want the focus to be on quality of life and comfort, no CPR.” Not one expressed a preference for life-extending measures.
Several physicians shared wrenching stories from personal experience. An ob/gyn began: “My dad was a type 2 diabetic. At ‘end of life’ he was hospitalized, on peritoneal dialysis, and ‘they’ decided that it would be a good idea to replace one of his heart valves (forget which one.) So they pulled all his teeth and sent him to the OR. Spent another month convalescing, then sent to a nursing home where he [discharged himself against medical advice] a few hours later (he had full use of his brain — NOTHING wrong upstairs). Went home and tried to kill himself by launching himself down the stairs. Back to the hospital with a broken arm. A few days later Mom calls me and tells me dad asked me to come home and kill him. After all, I’m a doctor and we know how to do that stuff. I told her that wasn’t going to happen. We then discussed alternatives and I suggested he simply discontinue his dialysis. A week later he died a much happier man.”
A primary care physician whose mother-in-law had died recently said: “She chose no medical or oncologic interventions after her hemi-colectomy 19 months ago. No pain meds, only supportive measures. A true profile in courage to choose to die on her own terms.”
And a psychiatrist stated, “My dad had pancreatic cancer with metastasis to the liver when it was diagnosed. We had a frank discussion about the benefits of chemo. He didn’t get it, we kept him at home with hospice, lorazepam, and morphine, and he died 6 weeks after the diagnosis. I’ll never know if it was the right or best choice, but it was better than dying in 8 or 12 weeks and suffering through chemo. I had surgery [the] year before last and made sure my advance directives were in place. I’m very clear that, unless my brain is intact and I have a chance at a decent quality of life, if something bad happens, pull the plug.”
A neurologist then questioned some basic hospital practices regarding end-of-life care: “The ICU should be for those few patients who will not just survive but be back into society. Examples include [patients with] Guillain-Barré syndrome, curable meningitis, ischemic ‘mini’ strokes, myasthenia gravis, ST-elevation myocardial infarction. [But they do not include] the octogenarians with irreversible comorbidities. Personally I feel unethical doing ‘follow-ups’ every day when the patient just requires the hospitalist to take care of their basic necessities.”
One topic that broke the general unanimity of opinion was physician-assisted suicide. Precisely how this should be viewed and administered brought out some slightly different opinions.
An anesthesiologist noted, “We need better access to and better understanding of euthanasia.”
But a psychiatrist countered by stating, “We have medications that can relieve most suffering… . All people can refuse or remove any medical intervention. All people can voluntarily stop eating and drinking. In my opinion, these interventions allow us to avoid the slippery slopes and ethical debates around euthanasia and physician-assisted suicide, not to mention keep us from the plethora of meanings these things have taken on. What we need is an educated public and profession about the options our patients have at the end-of-life, as well as the options we as professionals have to give them… . Most importantly, we need people nearing the end of life to have these discussions (which evolve over time and can change) and make sure they are documented or reside with a party that will be present when the time comes.”
But a primary care physician spoke up for allowing legal euthanasia as a viable option: “I have been very impressed by the outcomes in the states where careful availability of physician-assisted suicide was made legal. Very few people have availed themselves of this option! I suspect that the option has given physicians a kick in the pants to make sure that we are really good at making alternatives for treatment available.”
Most people are likely to face the issue of end-of-life care in some capacity, but few are as familiar with it as physicians are. Rarely does an issue evince both passion and a general consensus among physicians, but this one has. Perhaps the fact that doctors want extremely limited medical intervention for the terminal illness of themselves or their loved ones should be more widely publicized to the general public.
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