Monday, January 16, 2012

What Doctors Know — and We Can Learn

Physicians are more likely to sign advance directives and avoid rescue measures at the end of their lives

Last month, an essay posted by retired physician Ken Murray called “How Doctors Die” got a huge amount of attention, some negative but mostly positive. Murray tells the story of an orthopedic surgeon who, after being diagnosed with pancreatic cancer, chose not to undergo treatment. The surgeon died some months later at home, never having set foot inside a hospital again.

Critics said that the essay was a biased opinion of how one should die, not an actual analysis of how doctors actually do die. And indeed, much of Murray’s essay was anecdotal. Murray writes that his physician friends wear medallions with DNR, or Do Not Resuscitate, orders. They instruct their colleagues to not take any heroic measures and to keep them out of the ICU at the end of life. He’s even seen a colleague with a DNR tattoo, something I’ve been threatening to get for a long time.

(MORE: The Real Issues of End-of-Life Care)

And yet, there is good evidence that physicians have thought out end-of-life issues more thoroughly than laypeople and are more likely to decline medical intervention. For example, they sign advance directives far more often than the rest of us do. Less than half of severely or terminally ill patients have an advance directive in their medical records. These are legal documents that indicate the kind of medical care we prefer at the end of life and where we would like to spend our last few days or weeks. Contrast that to a study published a few years back that found 64% of doctors surveyed had signed such documents. Those who had were nearly three and a half times more likely to refuse rescue care, like CPR, compared with doctors who had not signed an advance directive.

Why would doctors be so anxious to avoid the very procedures they deliver to their patients every day? For one thing, they know firsthand that these procedures are most often futile when performed on a frail, elderly, chronically ill person. Only about 8% of people who go into cardiac arrest outside of the hospital are revived by CPR. Even when your heart stops in the hospital, you have only a 19% chance of surviving. That’s a far cry from the way these procedures are portrayed on TV, where practically everybody survives having his heart shocked and undergoing CPR.

Doctors also know that undergoing heroic measures is a lousy way to die. They’ve seen what it’s like for an elderly patient to end up in the ICU, hooked up to machines, often semiparalyzed, in pain, lying on what philosopher Sidney Hook called “mattress graves” during his own terminal illness. At a recent meeting I attended, one emergency physician tearfully admitted she didn’t think she could stand to hear the sound of ribs breaking as she perform CPR on yet another elderly patient who almost certainly would not survive.

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