"Do everything you can, doctor. Do anything it takes to save him."
These are the unfortunate pleas that too many patients and their families make when dealing with terminal illness and end-of-life decisions. While the use of advance directives helps alleviate this problem by informing doctors in advance about a patient's end-of-life wishes, there is still an underlying belief that medicine can cure everyone, even those people with the most terrible prognoses.
But doctors die differently than their patients. They often don't want the fancy treatment, the life-prolonging chemotherapy, or the 2-hour-long cardiac resuscitation (CPR). They know the consequences, and they just say no.
In 2011, physician Ken Murray wrote an anecdotal essay on physicians' end-of-life decisions called How Doctors Die. In 2012, Dr. Murray followed up with a second essay, Doctors Really Do Die Differently, which provided statistical evidence of the assertions he made in his first essay.
According to Dr. Murray, one physician friend was uninterested in taking advantage of his own invention to triple the survival rate of pancreatic cancer patients – from 5% to 15% – albeit with a poor quality of life. Instead, the physician left the hospital after his initial diagnosis, enjoyed time with his loved ones, and died a few months later.
While treating patients hooked up to dozens of tubes, machines, and medications, countless physician friends have said to Dr. Murray in varying ways, "Promise me if you find me like this that you'll kill me.' Some even wear jewelry marked "no code" to instruct providers to not perform CPR if the need arises
Of course, not all physicians follow the path Dr. Murray suggests. But in his second article, he provides statistical evidence of his experiences.
The Johns Hopkins Precursors Study was conducted based on the medical histories and decisions of a voluntary group of older physicians who graduated from the Johns Hopkins School of Medicine classes of 1948 through 1964. According to the study, 65% of the surveyed doctors had written an advance directive, whereas only about 20% of the public does so. Approximately 90% of the physicians responded that they would not want CPR if they were in a chronic coma, whereas only about 25% of the public gives the same answer.
So why do doctors die differently?
Every day, doctors see the effect of what they call "futile care." They see patients languishing in the ICU, attached to ventilators, tube feeds, and other devices keeping them alive. On the other hand, many patients only see what is on TV.
A 1996 study found that CPR showed on television was successful 75% of the time and that 65% of the patients went home. On the other hand, a 2010 study of more than 95,000 cases of CPR in Japan found that only 8% of patients survived for more than one month and of those, only about 3% led normal lives post-code. Approximately 3% were in a vegetative state, and about 2% were alive with a "poor" outcome. And a 2010 study looked at terminal patients who did not want CPR but got it anyway. Of the 69 patients studied, eight regained a pulse, but, within 48 hours, all were dead.
Physicians may also make different recommendations for their patients than they would follow themselves. Physicians often feel that failing to save a patient shows weakness and professional inadequacy. This sentiment does not necessarily carry over to saving themselves.
If physicians feel that certain end-of-life and terminal illness treatments are futile, they should be open and clear with their patients. While the ultimate decision belongs to you, the patient, sometimes it is time to say enough is enough. And your physician is in the best place to help you determine when that time is.
- By Erica B. Cohen