A Fascinating Look at How Doctors Choose to Die

Our final days are not like theirs. But they should be.

By Ken Murray, MD from zocalopublicsquare.org
Also in Reader's Digest Magazine July 2014

doctor's coatBrian Cronin for Reader’s Digest

YEARS AGO, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. The diagnosis was pancreatic cancer. His surgeon was one of the best: He had even invented a new procedure for this exact cancer that could triple the five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life.

Charlie was uninterested. He focused on spending time with family. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him. Several months later, he died at home.

Doctors die, of course—but not like the rest of us. What’s unusual is not how much treatment they get compared with most Americans but how little. They have seen what is going to happen, and they generally have access to any medical care they could want. But doctors prefer to go gently.

They know enough about death to understand what all people fear most: dying in pain and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen. They know modern medicine’s limits. Almost all medical professionals have seen “futile care” performed. 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. It buys 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.” Some medical personnel wear medallions stamped NO CODE to tell physicians not to perform CPR on them.

The Drawbacks of “Do Everything”

How has it come to this—that doctors administer care that they wouldn’t want for themselves? The simple, or not-so-simple, answer: patients, doctors, and the system.

Imagine that someone has lost consciousness and been admitted to an emergency room. When doctors ask family members—shocked, scared, and overwhelmed—if they want “everything” to be done, they answer yes. But often they just mean “everything that’s reasonable.” They may not know what’s reasonable, nor, in their confusion and sorrow, will they ask or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether reasonable or not.

People also have unrealistic expectations of what doctors can accomplish. Many think of CPR as a reliable lifesaver, when the results are usually poor. I’ve seen hundreds of people in the emergency room after they got CPR. Just one, a healthy man with no heart troubles, walked out of the hospital. Even though only a small percentage of healthy people will have a good response to CPR, we would always do it to give them that chance. But with terminal people, virtually no one responds. If a patient has severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal and the odds of suffering are overwhelming (see sidebar).

Physicians enable too. Even those who hate to administer futile care must address the wishes of patients and families. Imagine an emergency room with grieving, possibly hysterical, family members. Establishing trust under such circumstances is delicate. People may think a doctor is trying to save time, money, or effort—rather than attempting to relieve suffering—if he advises against further treatment.

Even when the right preparations have been made, the system can still swallow people. One of my patients was a 78-year-old named Jack; he had been ill for years and had undergone about 15 major surgeries. He explained to me that he never, under any circumstances, wanted to be placed on life support. One Saturday, Jack suffered a massive stroke and was admitted to the emergency room unconscious. Doctors did everything possible to resuscitate him, and they put him on life support. This was Jack’s worst nightmare. When I arrived and took over his care, I spoke to his wife and to hospital staff, bringing in my office notes with his preferences. Then I turned off the life-support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped; the system had intervened. A nurse, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying. I could far more easily have left Jack on life support against his wishes, prolonging his suffering. I would even have made a little more money, and Medicare could have ended up with an additional $500,000 bill.

Choosing Quality of Life

Doctors don’t overtreat themselves. Almost anyone can die in peace at home. Pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity, offers most people better final days. Studies have found that people in hospice often live longer than people with the same disease who seek active cures.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had spread to his brain. With aggressive treatment, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Torch decided against treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months having fun like we hadn’t had in decades. We went to Disneyland, his first time. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He had no serious pain and remained high-spirited. One day, he didn’t wake up; he spent the next three days in a coma-like sleep, then died.

Torch was no doctor, but he wanted a life of quality, not just quantity. If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. There will be no heroics; I hope to go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is a retired clinical assistant professor of family medicine at the University of Southern California.

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  • Your Comments

    • Marilyn

      I do not want any wasted end-of-life heroics. Just give me a pain med if needed and be sure I can breathe. Let nature take care of the rest. :)

    • fatbandit

      How about when you get the diagnosis of a terminal disease like the orthopod in the story that is expensive to treat and has a very low probability of survival you sign an agreement with medicare (or what ever insurance you have) that you will seek only palliative care in exchange for 40% of the expected cost to treat the illness aggressively. I’ve seen studies that state 50%+ of medicare/medicaid dollars are spent in the last year of a patients life with no effect on quality or quantity of life. Saves the system a load of money and stimulates the economy as you now have some cash to complete the bucket list

    • AFITgrad86

      It’s not so much the fear of death as it is the process of dying that I and others fear. I fear it less having sat with my mom and my wife’s parents as they each passed on. What is the most fearful is the uncertainty of when and how the passage will take place. I am reasonably healthy and 65 and have a DNR. I do not want extraordinary measures taken.

      • Nikki

        I feel the same way, and I think perhaps this is an important point that has been missed from this article. Doctors work so closely with the processes of life that they understand dying is an important and undeniable part of life. On the other hand, for their patients they understandably don’t want to allow the irreversible to happen without the patient and family being on board. I wonder if our distance from the natural world (animals and really relying on our own gardens to feed us) and changes in community culture has influenced the current generations perception of death?

        • AFITgrad86

          Agree … and you can probably add our distance from aging parents/relatives as the trend is to place sick and dying family members in care facilities rather than caring for them at home. But I also think faith is a large factor as well. Having the knowledge that there is more to death than the grave is a comfort.

      • fatbandit

        DNR is not enough. 15 years in emergency medicine and I have seen hundreds of DNRs violated by the family that shows up and says “You have to do everything for grandpa.” You must have a living will and medical power of attorney. The person you designate as your medical power of attorney MUST be someone that you know will follow your instructions to the letter when under the stress of your being unable to communicate your wishes. Make sure your documents go into specifics like feeding tubes and mechanical ventilation

    • G. Morse

      My late husband said it best… “The dying can take and awful lot of resources from the living.” When it’s my turn i would accept treatment ONLY if there is reasonable hope of a dignified, meaningful, achieving quality of life. Otherwise all that money spent on tubes, dialysis, etc. I would rather see go to a newborn baby. I have had my turn and a meaningful, achieving life. LET THE NEWBORN BABY STRUGGLING FOR LIFE HAVE THE RESOURCES, NOT ME IF I WILL DIE ANYWAY. I want the courage to go like the doctor in this article and instead of a funeral I want my friends to go to Starbucks and celebrate the life I lived.

    • Al Dente

      It isn’t always the family who wants too much care. At 78 my grandmother got very ill. We took her to the hospital and were sure enough that this was the end that we called the rest of the family who lived out of town to see her before she passed. After a few days she bounced back and wanted to go home. Doctors refused and ran test after test; they were sure she had some sort of cancer and were on a mission to find it. After tormenting her for days a family member thought to ask her doctor what they would do if they found cancer. He admitted that since she was too weak for surgery or chemo that there was probably nothing they could do for her. We took her out of the hospital. She had 1 more good year then got sick and died of cancer.

    • agoraks

      How about donate our living diseased bodies for human experimentation ? enough with the mouse BS. We send soldiers to kill for us and call them heroes how about we die in the name of humanity fighting cancer ?

      • patti3

        It sounds like you believe terminally ill patients have a moral duty to die. May they never lose their value as human beings.

        • agoraks

          a. its a choice
          b. yes its moral to die so you can save the life of generations. I would gladly take this chance..if given an opportunity.
          c. Cancer strips you from your value as human. Please visit any Hospice center and talk to the living zombies there.

    • Denise

      I really liked this article and agree with it. I’m a nurse who works in a LTAC (long term acute care facility). Most of the patients on my floor came to us from an acute care hospital because they are on a ventilator and couldn’t be weaned.(able to breath without it). We try to wean them off. It is a long process, takes months or years. Most of the elderly never get off the vent. They get one infection and complication after another until they finally die. Most of these patients also have g-tubes (tube implanted in their stomachs for nutrition) and some are also on dialysis. Most are full codes. I have coded patients in their nineties. Most of the time it is the family who wants “everything done.” To be fair, some patients want to be kept alive on a vent. I have no problem with that. But I think people really need to think about end of life issues, about quality of life versus quantity. A good book to read on this subject is “A Death Prolonged.” I can’t remember the author. It was written by a doctor and you can find it on Amazon.

    • Helarisi Wijekoon

      If I know for certain that I’m doomed to die in a few months I’d rather not be drowned in medicines and surgical procedures until the end. Yeah, I’d rather die in peace. It’s not a question of dignity really, but peace of mind. It’s no use spending your last days trying to fight a battle that can’t be won. However, if I know I have a fair chance of survival, I’ll go through the treatment anyway for the sake of my family and friends. So it all depends on the odds, and should it come to this, I can only hope the physicians can calculate the odds accurately and give me a clear picture of what will happen. I’m a medical student, by the way.

      • Joshua Fox

        I’m surprised you are still a student. Not to be a downer but I wouldn’t spend my time preparing for a future I know I will never have. Enjoy your time left.

      • fatbandit

        I hope you have completed the required paperwork in detail and have named someone you can trust to carryout your wishes.