guboogi.com

How Doctors Die→

Ken Murray writing for Zócalo Public Square on how doctors die:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Over the past year or so, I’ve been reading a lot of articles (at least by my standards) dealing with end-of-life situations, and I’ve found them all to be pretty fascinating (though also slightly depressing). I’d recommend reading the entire article — it’s rather short and to the point. Another really good article that I read was simply titled Letting Go. I also really liked this article in The Atlantic on the triumph of new-age medicine.

Death — especially our own — is clearly a topic that nobody likes to think about, but if there’s been one consistent message in the articles I’ve read, it’s been this:

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days.

[Zócalo via kottke.org]

What should medicine do when it can't save your life?→

“Is she dying?” one of the sisters asked me. I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

I spent the better part of an hour yesterday morning reading an article from The New Yorker entitled “Letting Go.” In the article, Dr. Atul Gawande discusses the role that medicine should play in the case of terminal illness — where death is all but inevitable — as well as the different goals of both standard medical care and hospice. It’s a long read, but it’s worth it. Fair warning: you may need a tissue.

Later on that afternoon, I was watching Source Code — a seemingly unrelated movie — when the main character asked: “What would you do if you knew you only had one minute to live?” The response he received: “I’d make those seconds count.” Cheesy Hollywood dialogue? Sure, but after reading that New Yorker article, it really hit home.

Nobody likes to think about how they would want to spend the final moments of their life, but suddenly there I was wondering just that. Would I fight til the bitter end? Or would I acknowledge my fate and try to make the best of whatever time I had remaining? Of course, regardless of how much time I spent on this decision now, it would be naive to think that I’d ever truly know what my answer will be until I’m actually forced to make it. That’s not to say that it’s not at least worth considering, though.

This is a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run — and when we imagine ourselves to have much more time than we do — our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something. We want these choices. We don’t want anyone — certainly not bureaucrats or the marketplace—to limit them. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something.

Like many things in life, there is no right or wrong answer. Many choose to hold onto whatever hope they may have, no matter how little, and good for them. Still, I thought this commentary on the current system was telling:

There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets — and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

[O]ur responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come — and to escape a warehoused oblivion that few really want.

Seriously, just read the article. [The New Yorker]

Wishing for a magic number→

All of this progress meant that the chance that Ruth’s breast cancer would come back was a lot lower than it might have been years ago. But what was that chance, anyway? It was the obvious question, and we put it to her oncologist at our first appointment with him. He paused and then offered a peculiar answer. He said we should realize that it didn’t matter. It would either happen or it wouldn’t.