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Friday, March 2, 2012

Doctors Die Differently

Many years ago, my late father received a recommendation for carotid artery surgery. He had no symptoms, but his physician was concerned about kinking and possible narrowing of the artery. I described the situation to a vascular surgeon colleague. He thought the recommendation was questionable. I encouraged my father to talk further with his physician about the procedure In their discussion the physician said - "I'm a worrier - I would do this for myself. But now that I hear more about your values, I don't think you should do it."

This exchange should have occurred before the recommendation was made. But the physician was commendably self aware and honest. (The artery never caused problems. My father died years later, at 89, of other causes.)

 When I was in clinical practice, patients sometimes asked me what I would do if I were in their situation. I thought this was a reasonable question. Interest in how our physicians care for themselves is more than idle curiosity. Their choices don't establish "truth." But knowing how they handle their own care and the values they bring to bear on their choices is useful "data" for our own reflection.

In a recent Wall Street Journal article - "Why Doctors Die Differently" - Dr. Ken Murray, a retired Assistant Professor of Family Medicine at the University of Southern California, tells how a physician mentor and a cousin both chose "low tech" end of life care for themselves. Dr. Murray cites a study of elderly graduates from Johns Hopkins Medical School that supports his anecdotes - a large majority would refuse a range of life-sustaining treatments. Here's how Dr. Murray puts it:

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.
Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).
Dr. Murray speculates that when patients ask their physicians how they would handle their own end of life care, we physicians are reluctant to answer. Though I haven't seen any research on the issue, his guess could well be right. End of life care involves the most personal choices we make, and physicians may hesitate to (a) reveal their own values and (b) exert too much influence.

But good medical care requires conversations of this kind. All too often overly intrusive end of life care happens by default. As a symptom of our pathological political culture, a proposal to reimburse primary care physicians for discussing our values for end of life care with us elicited (a) an accusation of "government death panels" from duplicitous politicians and (b) a mini-epidemic of public paranoia.