"How Doctors Die"

Friday, February 24, 2012 |

"But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble."

(full article here)


Anonymous said...

Great article

spacefan said...

This is a problem which is becoming more prevalent as an increasing number of patients and / or family members attain higher educational levels, earn bigger salaries, know their rights, or make demands based on "something I read in the papers / on the Internet / heard from so-and-so".

The public sector, with its limited resources, will bear the brunt of such conflicts. The private one, on the other hand, isn't known for judicious evaluation or management. And why should it? The patient waves a fistful of cash in front of you, expects EVERYTHING to be performed stat, and if you don't do it, s/he will just hop to the clinic next door.

Anonymous said...

I think, very often, it's also the filial piety thing that comes into play, especially when it relates to making decision for a very ill parent or grandparent. Had the terrible experience of having to decide (within 2 hours,timeline given by the attending doc) whether to place my dad on life support after unsuccessful chemotherapy for terminal cancer. Knowing it would be futile to aimlessly prolong his life with no quality, I decided against life support, but it was really heart wrenching, especially when some relatives felt that as children, it is rightful and noble for us to pursue all avenues to keep him alive, especially when we can still afford it.

From that agonising experience, I decided to make an AMD for myself to spare the relatives of having to make similar decisions but it was met with some difficulty as my family doc whom I approached to be the witness was reluctant as he was afraid that I might be planning on a suicide(!) even after I explained to him clearly the reason for my wish to make the AMD.

It would certainly help if docs are more familiar with the AMD and helpful (instead of making wild guesses) towards patients who want to make them.

Anonymous said...

AMD FAQ: Three doctors, including the patient's hospital doctor, must unanimously certify a patient's terminal illness. Two of the doctors must be specialists. “Terminal illness” under the AMD Act is an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery where — (a) death would, within reasonable medical judgment, be imminent regardless of the application of extraordinary life-sustaining treatment; and (b) the application of extraordinary life-sustaining treatment would only serve to postpone the moment of death of the patient.
I’m not sure in the general case whether it is reasonably clear to a doctor that death is imminent/merely momentarily postponed. That is, is uncertainty still the norm in the majority of cases, and family members are still confronted with the same dilemma? Comments anyone?

Anonymous said...

The world has changed. Sometimes if you can't beat 'em you gotta join 'em.

Seriously I have decided there is no point in "fighting". Work towards a synergistic relationship between doctor and patient. But if it fails then just work on the principle of making the customer happy.

Put it this way, the administrators do not give medals or rewards to doctors who are dead set on practising the best evidence based medicine and being totally dead honest to the point of making the customer unhappy.

So why bother? Save money for who? The people? Tax payers? The government? And then get penalised for doing so?

Forget it man. The irony is that all those people who say things like "this doctor is greedy, money faced etc". They don't realize that it is the ones they are most unhappy and dissatisfied with who are probably the most honest and altruistic ones!

This is what angry doc meant but as we can see, laymen are not privy to enough knowledge and insight to tell the difference.

While we can start off being good doctors, there is only so much you can do before you just have to get to what most thing is "best" for everyone.

angry doc said...

"Sometimes if you can't beat 'em you gotta join 'em."

Or you can just practise how you want and accept the consequences.

Anonymous said...

It would be interesting to see if you can still consider yourself practicing if there are no patients who want to see you everyday.

Of course that is an exaggeration. But you get the idea.