Southern California MD Ken Murray explained why many doctors wear «Don’t Pump Down» pendants and why they choose to die of cancer at home.
We leave quietly
“Many years ago, Charlie, a respected orthopedic surgeon and my mentor, discovered a lump in his stomach. He underwent exploratory surgery. Pancreatic cancer confirmed.
Diagnosis was carried out by one of the best surgeons in the country. He offered Charlie treatment and surgery, which would triple his life expectancy with this diagnosis, although the quality of life would be poor.
Charlie was not interested in this offer. He left the hospital the next day, closed his medical practice, and never returned to the hospital. Instead, he devoted all of his remaining time to his family. His health was as good as can be for a cancer diagnosis. Charlie was not treated with chemotherapy or radiation. A few months later he died at home.
This topic is rarely discussed, but doctors also die. And they don’t die like other people. It’s amazing how rarely doctors seek medical attention when the case is nearing its end. Doctors struggle with death when it comes to their patients, but they are very calm about their own death. They know exactly what will happen. They know what options they have. They can afford any kind of treatment. But they leave quietly.
Naturally, doctors do not want to die. They want to live. But they know enough about modern medicine to understand the limits of possibilities. They also know enough about death to understand what people fear most — death in agony and alone. Doctors talk about it with their families. Doctors want to make sure that when their time comes, no one will heroically save them from death by breaking their ribs in an attempt to revive them with chest compressions (which is exactly what happens when the massage is done correctly).
Virtually all health care workers have at least once witnessed a «vain treatment» when there was no chance that a terminally ill patient would get better from the latest advances in medicine. But the patient’s stomach is torn open, the TUEK is stuck into it, connected to the apparatus and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. With this money, people buy suffering that we will not inflict even on terrorists.
Doctors don’t want to die. They want to live. But they know enough about modern medicine to understand the limits of what’s possible.
I’ve lost count of how many times my colleagues have said something like this to me: «Promise me that if you see me like this, you won’t do anything.» They say it in all seriousness. Some doctors wear pendants that say «Do not pump out» to prevent doctors from giving them chest compressions. I even saw one person who made himself such a tattoo.
Treating people by causing them suffering is painful. Doctors are taught not to show their feelings, but among themselves they discuss what they are going through. “How can people torture their relatives like that?” is a question that haunts many doctors. I suspect that the forced infliction of suffering on patients at the behest of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions. For me personally, this was one of the reasons why I have not practiced in a hospital for the last ten years.
Doctor do everything
What happened? Why do doctors prescribe treatments they would never prescribe themselves? The answer, simple or not, is patients, doctors, and the medical system as a whole.
The patient’s stomach is torn open, the TUEK is stuck into it and poisoned with drugs. This is what happens in intensive care and costs tens of thousands of dollars a day. With this money people buy suffering
Imagine this situation: a person lost consciousness, and he was brought by ambulance to the hospital. No one foresaw this scenario, so it was not agreed in advance what to do in such a case. This situation is typical. Relatives are frightened, shocked and confused by the many treatment options. Head is spinning.
When doctors ask, «Do you want us to ‘do everything’?» family members say yes. And hell begins. Sometimes the family really wants to “do everything,” but more often than not, the family just wants everything to be done within reasonable limits. The problem is that ordinary people often do not know what is reasonable and what is not. Confused and grieving, they may not ask or hear what the doctor says. But physicians who are told to “do everything” will do everything without considering whether it is reasonable or not.
Such situations happen all the time. The matter is aggravated by sometimes completely unrealistic expectations about the «power» of doctors. Many people think that artificial heart massage is a win-win way of resuscitation, although most people still die or survive as severely disabled (if the brain is affected).
I have seen hundreds of patients who were brought to my hospital after resuscitation with artificial heart massage. Only one of them, a healthy man with a healthy heart, left the hospital on his own two feet. If the patient is seriously ill, old, has a fatal diagnosis, the probability of a good outcome of resuscitation almost does not exist, while the probability of suffering is almost 100%. Lack of knowledge and unrealistic expectations lead to poor treatment decisions.
Of course, not only the relatives of patients are to blame for this situation. Doctors themselves make useless treatments possible. The problem is that even doctors who hate futile treatment are forced to satisfy the desires of patients and their families.
The forced infliction of suffering on patients at the request of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions.
Imagine: relatives brought an elderly person with an unfavorable prognosis to the hospital, sobbing and fighting in hysterics. For the first time they see a doctor who will treat their loved one. To them, he is a mysterious stranger. In such conditions, it is extremely difficult to establish trusting relationships. And if the doctor starts discussing the issue of resuscitation, people tend to suspect him of not wanting to mess with a difficult case, saving money or his time, especially if the doctor does not advise continuing resuscitation.
Not all doctors know how to speak to patients in a clear language. Someone is very categorical, someone sins with snobbery. But all doctors face similar problems. When I needed to explain to the patient’s relatives about the various treatment options before death, I told them as early as possible only those options that were reasonable under the circumstances.
If relatives offered unrealistic options, I simply conveyed to them all the negative consequences of such treatment in simple language. If the family still insisted on treatment that I considered pointless and harmful, I offered to transfer them to another doctor or another hospital.
Doctors do not refuse treatment, but retreatment
Should I have been more assertive in persuading relatives not to treat terminally ill patients? Some of the cases where I refused to treat a patient and referred them to other doctors still haunt me.
One of my favorite patients was a lawyer from a prominent political clan. She had severe diabetes and terrible circulation. There is a painful wound on the leg. I tried to do everything to avoid hospitalization and surgery, realizing how dangerous hospitals and surgery are for her.
She nevertheless went to another doctor whom I did not know. That doctor had little to no knowledge of the woman’s medical history, so he decided to operate on her by shunting the thrombotic vessels in both legs. The operation did not help restore blood flow, and postoperative wounds did not heal. Gangrene went on her feet, and both legs were amputated to the woman. Two weeks later, she died in the famous hospital, where she was treated.
Both physicians and patients are often victims of a system that encourages overtreatment. Physicians in some cases get paid for every procedure they do, so they do whatever they can, whether the procedure helps or hurts, just to make money. Much more often, however, doctors are afraid that the patient’s family will sue, so they do everything that the family asks, without expressing their opinion to the patient’s relatives, so that there are no problems.
Both physicians and patients are often victims of a system that encourages overtreatment. Doctors sometimes get paid for every procedure they do, so they do the best they can, whether the procedure helps or hurts.
The system can devour the patient, even if he prepared in advance and signed the necessary papers, where he expressed his preferences for treatment before death. One of my patients, Jack, had been ill for many years and had 15 major surgeries. He was 78. After all the vicissitudes, Jack absolutely unequivocally told me that he never, under any circumstances, wants to be on a ventilator.
And then one day Jack had a stroke. He was taken to the hospital unconscious. The wife was not around. The doctors did everything possible to pump him out, and transferred him to the intensive care unit, where he was connected to a ventilator. Jack was afraid of this more than anything in his life! When I got to the hospital, I discussed Jack’s wishes with the staff and his wife. Based on the papers written with Jack’s participation and signed by him, I was able to disconnect him from the life-sustaining apparatus. Then I just sat down and sat with him. He died two hours later.
Despite the fact that Jack made all the necessary documents, he still did not die the way he wanted. The system intervened. Moreover, as I found out later, one of the nurses slandered me for disconnecting Jack from the machines, which means that I committed murder. But since Jack wrote down all his wishes in advance, there was nothing for me.
Hospice caregivers live longer than people with the same illness who are treated in the hospital
Yet the threat of a police investigation strikes terror into any doctor. It would be easier for me to leave Jack in the hospital on the equipment, which is clearly contrary to his wishes. I’d even make more money, and Medicare would get billed for an extra $500,000. No wonder doctors tend to overtreat.
But doctors still do not cure themselves. They see the consequences of retreatment every day. Almost everyone can find a way to die peacefully at home. We have many options to ease the pain. Hospice care helps terminally ill people spend the last days of their lives comfortably and with dignity, instead of suffering from unnecessary treatment.
It is amazing that people who are cared for in a hospice live longer than people with the same illness who are treated in a hospital. I was pleasantly surprised when I heard on the radio that renowned journalist Tom Wicker «died peacefully at home surrounded by family.» Such cases, thank God, are becoming more common.
A few years ago, my older cousin Torch (torch — lantern, burner; Torch was born at home by the light of a burner) had a cramp. As it turned out, he had lung cancer with brain metastases. I spoke to various doctors and we learned that with aggressive treatment, which meant three to five visits to the hospital for chemotherapy, he would live for about four months. Torch decided not to be treated, moved to live with me and only took pills for cerebral edema.
For the next eight months, we lived for our own pleasure, just like in childhood. For the first time in my life we went to Disneyland. We sat at home, watched sports programs and ate what I cooked. Torch even recovered on home grubs. He was not tormented by pain, and the mood was fighting. One day he didn’t wake up. He slept in a coma for three days and then died.
Torch wasn’t a doctor, but he knew he wanted to live, not exist. Don’t we all want the same? As for me personally, my doctor is aware of my wishes. I’ll quietly go into the night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.