Hi Udhay, I am not sure if my voice counts as that of practicing physician, i have to admit i have met some life extension folks among my physician acquaintances :) Regards Anish
Anish Mohammed Twitter: anishmohammed http://uk.linkedin.com/in/anishmohammed Skype: thecryptic On 22 Oct 2013, at 05:13, Udhay Shankar N <[email protected]> wrote: > Doctors on silk - is this borne out by your experience? > > Udhay > > http://www.alternet.org/personal-health/doctors-secret-how-die-right?paging=off¤t_page=1 > > Doctors' Secret for How to Die Right > Why do physicians make different end-of-life choices than the rest of us? > > October 14, 2013 | > > Dr. Ken Murray wrote an essay for the web-only magazine Zócalo Public > Square, thinking he’d be lucky to attract a few dozen readers and > generate an online comment or two. Instead, the physician—a UC Davis > medical-school graduate who taught family medicine at the University of > Southern California—drew an avalanche of responses. In fact, what he > wrote put him center stage in a swirling debate about life, death and > doctors. > > What did he reveal that was so groundbreaking? > > He claimed that a vast majority of physicians make dramatically > different end-of-life choices than the rest of us. Put simply, most > doctors choose comfort and calm instead of aggressive interventions or > treatments, he said. Another way to look at it is that doctors routinely > order procedures for patients near the end of life that they would not > choose for themselves. > > What do doctors know that the rest of us don’t? > > According to Murray, physicians have seen the limitations of modern > medicine up close and know that attempts to prolong a life can often > lead to a protracted, heartbreaking death. > > Murray’s 2011 “How Doctors Die” was translated into multiple languages > and written about in The New York Times, The Wall Street Journal, The > Washington Post and The Sacramento Bee. Thousands of people commented on > it via the scores of newspapers and blogs that reprinted it. Readers > told of “near-dead relatives being assaulted with toxic drugs,” said > Murray, being offered “painful procedures for no good reason.” Among the > responses were hundreds of anecdotes from physicians and health-care > professionals that backed Murray’s thesis. > > “Most of the stories were heart-wrenching,” he said. > > Data that proves the divide isn’t hard to find. Murray cites the Johns > Hopkins Precursors Study, one of the longest longitudinal inquiries into > aging in the world, which contains a running medical record of health > statistics on a group of about 750 doctors, who were members of the > Johns Hopkins University School of Medicine in Baltimore between 1948 > and 1964. Through the years, the study has helped medical research > correlate, for example, high blood cholesterol with heart attacks. But > 15 years ago—with its participants in their 60s, 70s and 80s—the > researchers began asking about end-of-life choices. > > Dr. Joseph Gallo, director of the Precursors Study, was happy to explain > how the data has continually found that doctors—by a vast majority—make > different choices when faced with dire diagnoses. Physicians who choose > the least procedures also tend to have advance directives, an important > bit of paperwork that allows patients to choose a health-care proxy and > determine in advance what interventions they do or don’t want if they > experience a decline in health. > > In one scenario where the study group was asked what their wishes would > be if they had an irreversible brain disease that left them unable to > recognize people or speak, “most people would want everything,” said > Gallo, while about 90 percent of doctors “would say no” to CPR, a > mechanical ventilator (breathing machine), and kidney dialysis. About 80 > percent of the doctors would also say no to major surgery or a feeding > tube, he said. > > “It seems the more familiar you are with interventions, the less you > want,” Gallo said point-blank. > > Welcome to “the gap.” > > Murray believes blame for the breach can be split three ways between bad > physician-patient communication, unrealistic expectations on the part of > patients, and their families and a health-care system that encourages > excessive treatment. (Note: A quarter of all Medicare spending occurs in > the last year of life.) > > ‘Don't tube me' > > When you consider the large number of deaths Sutter Health’s Dr. James > McGregor has witnessed in his decades as a Sacramento-area specialist in > palliative care and hospice, it is poignant to see him almost overtaken > with emotion while telling the story of Ella. > > An elderly woman diagnosed with a terminal illness, Ella (not her real > name) had strong feelings about not having any medical interventions as > she neared her life’s end. She’d filled out her paperwork to this effect > and made it official, with her husband serving as her health-care agent > in the event that she became unable to make her own decisions. Soon came > the inescapable point when Ella, stretched out on a hospital bed and > near the end of life, began having difficulty breathing. One of her many > doctors said to the husband, “She’s struggling so much. Don’t you want > her on a respirator?” Thinking the doctor knew best, the husband gave > his consent, and Ella was hooked up to a breathing machine. > > That one moment’s choice turned into seven long days of regret. > > Despite her wishes, Ella remained marginally alive in the intensive care > unit with “tubes everywhere” and a machine breathing for her throughout > the week. According to McGregor, the husband then had to take > responsibility to withdraw care. “He was heartbroken,” said McGregor. > “He felt he had betrayed his wife during her last week of life. … You > could see such pain.” > > McGregor, an expert in hospice care (which provides terminally ill > patients with comfort rather than aggressive treatments) and palliative > medicine (with its focus on relieving and preventing suffering), said > Ella’s experience was probably more common than most people know. > > “I’ve seen patients die in the ICU with every line going, everything, > and the family can’t even get close to them.” > > Indeed, though most people want to pass away at home surrounded by loved > ones, 70 percent die in a hospital, nursing home or long-term-care > facilities after a long struggle with advanced cancer, heart failure, > incurable disease or the multiple incapacities of old age. > > When asked about the gap and why doctors don’t tend to find themselves > hooked to respirators in ICUs at the end of their lives in the manner of > Ella, McGregor was somber. > > “Often the question isn’t framed well,” said McGregor, as in, “’We have > two options here: We can go full-court press, or we can aggressively > manage your symptoms and keep you comfortable. What would be quality of > life for you?’” > > Physicians, he said, tend to choose option No. 2, because they’ve seen > what they’ve seen, and “they know one intervention can start a whole > cascade.” > > Dr. Kevin Ryan, a retired physician and a self-published author, puts it > a different way: “Doctors have seen [death and dying] from every vantage > point except it personally happening to them. > > “When you’re close to the fire, you know what it is to get burned.” > > Medicine and hospitals exists to fight disease and death, goes the > thinking, so if a patient dies, the doctor has failed. > > McGregor remembered a clinical-skills class he’d taken in medical school > that imparted a first-person list of steps a physician should take that > concluded with the words “if the patient dies, I failed.” > > “We’re supposed to do things, we’re supposed to fix things,” said > McGregor. “Physicians can feel powerless if they can’t offer something, > and it’s difficult for them to talk about the options that are not the > aggressive ’making you healthy’ options. … A physician can feel he’s > failed a patient when he says, ’Well, you can go to hospice.’” > > Indeed, a report published last year in the New England Journal of > Medicine found that 69 percent of lung-cancer patients and 81 percent of > colorectal-cancer patients did not report understanding from their > doctor that chemotherapy was not at all likely to cure their cancer. > > But it runs two ways, said McGregor. > > The patient or the family can often come in with vastly unrealistic > expectations, sometimes reinforced by popular culture. Many see CPR, for > example, as a sure-bet lifesaver, but in truth, it is rarely effective. > “There’s a popular misperception that medicine can fix everything,” he > said. “And there’s also a sense of entitlement sometimes—’You should > give me everything.’” > > Sadly, another reason physicians sometimes “do everything” with terribly > ill patients is fear of malpractice lawsuits. > > “I believe it is a factor,” said McGregor. The other doctors interviewed > agreed. “Sometimes, [physicians] just say, ’OK, we’ll give you > everything,’ even though we know it’s not going to help” as a way of not > becoming entangled in a legal action from a family member who thought > more procedures were merited, he said. > > As for his own end-of-life wishes, if faced with a terminal illness, his > wish is to die at home without interventions and with the assistance of > hospice. > > “I joke that I have DNR, DNAR and AND tattooed on my chest,” said > McGregor (do not resuscitate, do not attempt resuscitation, allow > natural death). > > “Just don’t tube me,” he clarified. > > ‘No way are they doing that to me' > > Dr. Michael GuntherMaher, the medical director for the Sacramento and > Roseville Kaiser tells the story of Sophie. > > An 88-year-old African-American woman, Sophie (not her real name) > checked into Kaiser a few months back with a history of rapid weight > loss and an infection called sepsis, said GuntherMaher. “We did some > tests and found she was anemic. We scanned her abdomen … and we found a > mass. It was very clear she had cancer,” he said. > > Initially, Sophie said she wanted the doctors to do everything possible > to save her life, said GuntherMaher. At the family’s strong urging, the > hospital proceeded to pull out all the stops with interventions and > drugs. “And this woman just slowly died in the ICU with a tube down her > throat,” he said. “The family finally said, ’Take her off the machine.’ > It was a very difficult and protracted ending to her life when there was > no reasonable hope any of it would work.” > > GuntherMaher, who had been asked to consult on Sophie’s case in his role > as a palliative specialist, reflected that the woman had given up the > chance to return to Oakland to die peacefully in her own surroundings, > “around friends and family who wanted so much to visit her, to say > goodbye. … That opportunity was completely lost,” he said. > > “I have a lot of stories like this,” he said. “The hospital is full of > them.” > > GuntherMaher views Sophie’s case as an example of what he refers to as > the chaos that accompanies many end-of-life scenarios. > > “A lot of life changes go on in the later years, and families are > ill-prepared,” he said. “There’s illness. People are in and out of > hospitals or nursing homes. They’re in these places, even though they > used to think, ’I never wanted it to be like that.’ But there they are. > And it’s chaotic.” > > It was a desire to help make order out of such end-of-life turmoil that > led GuntherMaher on the path to his current post at Kaiser. > > “I think most people … what they have is fear,” he said. “They’re > afraid. They’re confronted. There’s unfinished business. They can’t > accept that things will come to an end this way because they’re so not > ready.” > > This state of mind, he said, often lays the ground for patients or their > families to go for whatever procedures are offered, however aggressive. > > GuntherMaher believes patients should be able to choose for themselves > whether or not to undergo treatments near the end of life. “I’m all for > people choosing,” he said, “as long as it’s informed.” > > Asked why doctors die different, as in Murray’s thesis, GuntherMaher > responded, “Doctors are different.” > > “As a group, we tend to be on the end of the spectrum where you find > capable, intelligent people. So, if you take [such] people and expose > them to these complexities and these difficulties over and over again, > they’re going to take that and process it. > > “The other thing we [doctors] are able to do is reconcile the physiology > issues, the biology failing, with the more difficult slippery human > issues. What is a life? What is death? What’s it all about? We’re > confronted with that on virtually a daily basis. Nobody else in our > society is, except maybe pastors.” > > GuntherMaher said the physicians he hangs out with are in the hospital > daily and “most of them who have been vocal about [interventions near > the end of life] have basically said, ’No way are they doing that to me.’” > > It was no surprise to find that GuntherMaher’s end-of-life choices echo > that of other doctors in the Johns Hopkins’ study. In fact, he’d > gathered his three 20-something children just a few months ago for a > meeting about his wishes. His son and daughter were with there in person > and “We got my daughter and son-in-law on FaceTime on the iPad,” he > said. GuntherMaher pulled out his advance directive and showed his > children a POLST form. Physician Orders for Life-Sustaining Treatment > forms state what kind of medical treatment seriously ill > patients—usually already in the hospital or a nursing facility—want for > themselves. > > “I think it provided a good opportunity for us to be a family and talk > about something meaningful together and practice compassionate listening > and thoughtful speaking with one another,” he said, “and consider for a > moment that time is precious.” > > Among other things, GuntherMaher told them, “I don’t want to be > resuscitated if my heart stops. I don’t want to be on a mechanical > ventilator. When my time comes, I want to die in my own home.” > > ‘Medicine can't fix everything' > > Dr. Jeffrey Yee stands before his students—gray button-down shirt, > khakis and a pocket pager—with all the friendly charisma of a > social-science professor. But he’s a doctor who takes time from his paid > duties as a general internist to teach elderly and chronically ill > patents about advanced directives and POLST forms. Yee’s audience in > early September consisted of 14 elderly patients—many of whom looked to > be struggling with chronic disease or cancer. > > Yee, who testified in 1997 on behalf of POLST before the state > Legislature, led his students through a PowerPoint presentation on > advance directives and the importance of naming a health-care agent or > proxy. He and a nurse practitioner even performed a skit where the two > played siblings with different interpretations of what a doctor > recommended should be done with a mom on life support. > > “We try to get people to consider the issues beforehand, to have > conversations,” Yee said before the class. “We try to get people to > experience the tensions and trade-offs they very well may face in the > future.” > > Launched six months ago, Yee’s group-education project is one of many > approaches being taken across the country to better inform people about > their options. Modeled after a much-lauded program at Gundersen Lutheran > Medical Center in Lacrosse, Wis., which proactively encourages > hospitalgoers to fill out advance directives, Yee’s patients are invited > to attend the two free classes by their doctor if their medical record > triggers them as age 60 with a chronic illness (diabetes, heart failure, > lung problems) or if they are simply 70 or older. > > Yee doesn’t use “end-of-life” terminology or the word “death” in his > seminars. Nor does he discuss specific procedures and their possible > outcomes. “When you reduce it to a conversation about ’this procedure > succeeds this amount of time,’ that doesn’t really give you the big > picture,” he said. “What number should it be that you say, ’This is a > low chance of success’?” he asked. If you’re 95, he said, you might > answer that question differently than if you are 30 and have three kids. > > Interestingly, Yee—the youngest doctor interviewed—was the only local > physician who didn’t immediately say he would decline interventions if > he himself was faced with a terminal illness. “It depends on the > situation,” he said. “I don’t know that I could specify that so > specifically now.” > > Another program that could result in narrowing the gap between > physicians and everybody else on end-of-life choices is dubbed ROYL, > short for The Rest of Your Life. > > Dr. Philip Lisagor, a retired cardiothoracic surgeon and chief medical > officer for ROYL in Reno, Nev., had a realization toward the end of his > career: “It struck me that nobody was talking to patients with serious > illnesses about what was happening,” he said. > > “A specialist would come in with some high-tech procedure and send them > back to the referring doctor. Something else would happen to the > patient, and they’d be off for another procedure. Doctors weren’t > talking to each other or to their patients. > > “A game is played,” he said. > > Lisagor noted that the profit motive should not be overlooked when > discussing why the gap exists, and so many doctors often encourage > interventions they themselves wouldn’t choose. “The health-care industry > makes a huge amount of money on end-of-life care,” said Lisagor. Indeed, > about 27 percent of Medicare’s annual $327 billion budget—$88 > billion—now goes to care for patients in their final year of life. > > “Everyone in the system profits from more procedures,” said Lisagor, > “including doctors, hospitals, pharmaceutical companies, people down the > line in diagnostic centers and etc. … It’s an enormous issue.” > > Since retiring, Lisagor and colleagues set up the ROYL program, an > online organizational system that walks people through “all the > documents and information necessary for you to plan your life and health > aging.” ROYL (www.theroyl.com) encompasses financial, emotional and > physical issues in addition to medical and end-of-life planning. He > hopes to beta test at a skilled nursing facility in the Reno area soon > and, eventually, take the program out to the country. > > Some believe pilot programs like Yee and Lisagor’s will fasten together > with other sweeping trends—the growth in hospital-based palliative-care > programs, increased use of POLST forms, an uptick in the number of > people dying in hospice care—and create a seismic shift in how America, > and not just its doctors, faces death. > > Nudging along that transformation could be the huge numbers of baby > boomers who have begun turning 65 (about 8,000 per day) and, thus, > looking at their final chapter of life. In the social realm, members of > this inimitable generation may set their sights on experiencing better > deaths than the often-troubling ones they have been seeing their parents > undergo. On the economic front, the boomers present a major financial > incentive for addressing the issue, since Medicare costs for this single > generation are projected to skyrocket if end-of-life scenarios remain > status quo. > > Though a proposal to reimburse doctors for talking about end-of-life > choices with patients was ultimately left out of the Affordable Care Act > (thanks to Sarah Palin’s 2009 charge that such conversations amounted to > “death panels” for “grandma”) many, like Ken Murray, think that > controversy actually got people finally talking and thinking about > end-of-life matters. > > “There’s a cultural change taking place across the country,” said > Murray, the doctor with the oft-reprinted essay. “The taboo is > unraveling. People want to talk about this. … It’ll take time, but I > believe it’s happening.” > > The physicians interviewed for this story also tended to agree that > things were improving in the end-of-life care realm. > > “I do think it’s getting better,” said McGregor. “I think what people > need to understand is that there is the possibility of having a > comfortable death, of mending relationships and dying surrounded by > loved ones. People need to understand this as a real and viable option. > > “And they need to understand that medicine can’t fix everything.” > > Will better communication, reasonable expectations and a hoped-for > future health-care system where financial incentives no longer skew > toward senseless interventions help narrow Murray’s gap and increase the > possibility for more “good” deaths? > > Naturally, the doctors hope so. > > But perhaps Dr. GuntherMaher’s patient Clarice, can best give testament. > > In her early 60s, Clarice (not her real name) was diagnosed in February > with kidney cancer. “She was not curable,” he said. After doing some > tests, “We told her, ’This is not looking good. You have advanced > cancer, and you’re too weak to undergo chemotherapy, which means you > don’t have any reasonable options for beating this.’” > > Clarice appreciated the candor, said GuntherMaher. > > “She has a spiritual belief system. She has a healthy marriage, healthy > relationships with her kids, and she said, ’I’ll be OK with this. I want > to go home and be with my family and let them take care of me. I can > still enjoy some time with them.’” > > She left the hospital and went into hospice, said the doctor. “I spoke > to her daughter yesterday, and they’re flying her sister home from Guam. > … The family is coming together. The children are saying, ’I’m dropping > everything to be with Mom.’ There’s a time in life when you just do that.” > > In other words, Clarice accepted her fate and prepared for her own good > death. She knew what she wanted. She made her choices. She embraced a > truth about dying that most physicians already know all too well: Often > doing less allows so much more. > > > -- > ((Udhay Shankar N)) ((udhay @ pobox.com)) ((www.digeratus.com)) >
