Southern California MD Ken Murray explained why many doctors wear Do Not Pump pendants and why they choose to die of cancer at home.
We leave quietly
“Many years ago, Charlie, a respected orthopedic surgeon and mentor of mine, discovered a lump in his stomach. He underwent a diagnostic operation. Pancreatic cancer was confirmed.
Diagnosis was carried out by one of the best surgeons in the country. He offered Charlie treatment and surgery that would triple his life span with such a diagnosis, although the quality of life would be low.
Charlie was not interested in this offer. He was discharged from the hospital the next day, closed his practice and never came to the hospital again. Instead, he devoted all of his remaining time to his family. He was feeling as good as possible when diagnosed with cancer. Charlie was not treated with chemotherapy or radiation. Several months later, he died at home.
This topic is rarely discussed, but doctors die too. And they don't die like other people. It is striking how rarely doctors seek medical attention when a case draws to a close. Doctors struggle with death when it comes to their patients, but are very calm about their own death. They know exactly what will happen. They know what options they have. They can afford any type of treatment. But they leave quietly.
Naturally, doctors don't want to die. They want to live. But they know enough about modern medicine to understand the limits of possibilities. They also know enough about death to understand what people fear most - death in torment and alone. Doctors talk about this with their families. Doctors want to be sure that when their time comes, no one will heroically save them from death by breaking their ribs in an attempt to revive them with chest compressions (which is exactly what happens when the massage is done correctly).
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Almost all health workers have at least once witnessed a "vain treatment" when there was no possibility that a terminally ill patient would get better from the latest medical advances. But the patient's stomach is ripped open, tubes are stuck into it, connected to machines and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. For this money, people buy suffering that we will not cause even terrorists.
I lost count of how many times my colleagues told me something like the following: "Promise me that if you see me in this state, you will not do anything." They say this in all seriousness. Some doctors wear pendants with the inscription “Do not pump out” so that doctors do not give them chest compressions. I even saw one person get this tattoo done.
Healing people by causing them suffering is painful. Doctors are taught not to show their feelings, but among themselves they discuss what they are experiencing. “How can people torture their relatives like that?” Is a question that haunts many doctors. I suspect that the forced infliction of suffering on patients at the request of families is one of the reasons for the high rates of alcoholism and depression among healthcare workers compared to other professions. For me personally, this was one of the reasons why I have not been practicing in a hospital for the last ten years.
What happened? Why do doctors prescribe treatments they would never prescribe to themselves? The answer, simple or not, is patients, doctors, and the medical system as a whole.
Imagine this situation: a person fainted and was brought by ambulance to the hospital. Nobody foresaw this scenario, so it was not agreed in advance what to do in such a case. This situation is typical. Relatives are scared, overwhelmed and confused about the many treatment options. Head is spinning.
When doctors ask “Do you want us to“do everything”? The family says“yes”. And hell begins. Sometimes the family really wants to “do it all,” but more often the family just wants it to be done within reasonable limits. The problem is that ordinary people often do not know what is reasonable and what is not. Confused and grieving, they may not ask or hear what the doctor is saying. But doctors who are commanded to “do everything” will do everything without reasoning whether it is reasonable or not.
Such situations happen all the time. The matter is aggravated by sometimes completely unrealistic expectations about the "power" of doctors. Many people think that artificial heart massage is a safe way to resuscitate, although most people still die or survive severely disabled (if the brain is affected).
I accepted hundreds of patients who were brought to my hospital after resuscitation with artificial heart massage. Only one of them, a healthy man with a healthy heart, left the hospital on foot. If the patient is seriously ill, old, and has a fatal diagnosis, the probability of a good outcome of resuscitation is almost non-existent, while the probability of suffering is almost 100%. Lack of knowledge and unrealistic expectations lead to poor treatment decisions.
Of course, it is not only the patients' relatives who are to blame for this situation. Doctors themselves make useless treatments possible. The problem is that even doctors who hate vain treatment are forced to satisfy the wishes of patients and their families.
Imagine: relatives brought an elderly person with a poor prognosis to the hospital, crying and hysterical. For the first time they see a doctor who will treat their loved one. For them, he is a mysterious stranger. In such conditions, it is extremely difficult to establish trusting relationships. And if a doctor begins to discuss the issue of resuscitation, people tend to suspect him of unwillingness to tinker with a difficult case, saving money or their time, especially if the doctor advises against continuing resuscitation.
Not all doctors know how to communicate with patients in an understandable language. Someone is very categorical, someone snobbery. But all doctors face similar problems. When I needed to explain the patient's relatives about the various treatment options before death, I told them as soon as possible only about those options that were reasonable in the circumstances.
If my relatives offered unrealistic options, I conveyed to them all the negative consequences of such treatment in simple language. If the family nevertheless insisted on treatment that I considered pointless and harmful, I suggested that they be transferred to another doctor or another hospital.
Doctors refuse treatment, but retreatment
Should I have been more persistent in persuading relatives not to treat terminally ill patients? Some of the cases where I refused to treat a patient and referred them to other doctors still haunt me.
One of my favorite patients was a lawyer from a famous political clan. She had severe diabetes and terrible circulation. There is a painful wound on the leg. I tried to do everything to avoid hospitalization and surgery, realizing how dangerous hospitals and surgery are for her.
She still went to another doctor whom I did not know. That doctor almost did not know the medical history of this woman, so he decided to operate on her - to bypass the thrombus vessels on both legs. The operation did not help restore blood flow, and the postoperative wounds did not heal. Gangrene developed on the feet, and both legs were amputated. Two weeks later, she died in the famous hospital where she was treated.
Both doctors and patients are often victims of a system that encourages over-treatment. Doctors in some cases get paid for every procedure they do, so they do everything they can, regardless of whether the procedure helps or hurts, just to make money. Much more often, doctors are afraid that the patient's family will sue, so they do everything that the family asks, without expressing their opinion to the patient's family, so that there are no problems.
The system can devour the patient, even if he prepared in advance and signed the necessary papers, where he expressed his preferences for treatment before death. One of my patients, Jack, has been ill for many years and has had 15 major surgeries. He was 78. After all the twists and turns, Jack absolutely unequivocally told me that he never, under any circumstances, wants to be on ventilator.
And then one day Jack had a stroke. He was taken to the hospital unconscious. The wife was not there. Doctors did everything possible to pump it out, and transferred to the intensive care unit, where they connected it to a ventilator. Jack was afraid of this more than anything in his life! When I got to the hospital, I discussed Jack's wishes with the staff and his wife. Based on documents drawn up with Jack's participation and signed by him, I was able to disconnect him from the life-supporting equipment. Then I just sat down and sat with him. He died two hours later.
Despite the fact that Jack made all the necessary documents, he still did not die the way he wanted. The system intervened. Moreover, as I found out later, one of the nurses cheated on me for disconnecting Jack from the machines, which means that I committed murder. But since Jack had written all his wishes in advance, there was nothing for me.
Yet the threat of a police investigation strikes fear into any doctor. It would have been easier for me to leave Jack in the hospital on the apparatus, which clearly contradicted his wishes. I would even make some more money, and Medicare would get an extra $ 500,000 bill. Unsurprisingly, doctors tend to over-treat.
But doctors still do not overheal themselves. They see the effects of retreatment every day. Almost everyone can find a way to die peacefully at home. We have many ways to relieve pain. Hospice care helps terminally ill people spend the last days of their lives comfortably and with dignity, instead of suffering unnecessary treatment.
It is striking that people who are cared for by hospice live longer than people with the same conditions who are treated in a hospital. I was pleasantly surprised when I heard on the radio that the famous journalist Tom Wicker "died peacefully at home surrounded by his family." Such cases, thank God, are becoming more common.
Several years ago, my older cousin Torch (torch - torch, torch; Torch was born at home by the light of a torch) had a seizure. As it turned out, he had lung cancer with brain metastases. I talked to various doctors and we learned that with aggressive treatment, which meant three to five visits to the hospital for chemotherapy, he would live for about four months. Torch decided not to be treated, moved to live with me and only took pills for cerebral edema.
For the next eight months we lived happily, just like in childhood. We went to Disneyland for the first time in our life. We sat at home, watched sports programs and ate what I cooked. Torch even recovered from home grubs. He was not tormented by pain, and his mood was fighting. One day he did not wake up. He slept in a coma for three days and then died.
Torch was not a doctor, but he knew he wanted to live, not exist. Don't we all want the same? As for me personally, my doctor has been informed about my wishes. I will quietly leave into the night. Like my mentor Charlie. Like my cousin Torch. Like my colleagues are doctors.
Translated by Anton Mikhailov