Interesting article on dying

[Evergrey]

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Atul Gawande writes about how we as a society have forgotten how to die:

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=1

Haven't finished reading it yet, but I will post my thoughts later. What do you guys think?

 

[Cypher321]

And if one plans to cheat death...?

The article itself reminds me of a surgeon I stayed with in Australia that would always start with "I always like to give it to people straight..." when it was a terminal case..interesting read.

 

[LizzyM]

"A family meeting is a procedure, and it requires no less skill than performing an operation."

Dr. Susan Block, palliative-care specialist​

OP, thank you for bringing that article to my attention.

 

[Narmerguy]

Great read, thanks for linking. I think this highlights part of the issues that many point out about the US system that we attempt to do so much and manage so many comorbities that we end up spending more than everyone else despite the skill and knowledge of our doctors.

It seems like he's trying to advocate hospice care as the solution to this problem (at least to some degree) which I suppose could be a viable option, but I'm not sure if the field would be equipped to really handle the flux of patients it would receive if this was used on a bigger scale. I think he also has selected some of the most exceedingly excessive examples to prove his point, and that the situations may not always be so egregious. Nonetheless, I'm curious what the perspective would be of attendings (and residents) in fields such as oncology, surgery, etc on this writing.

 

[Shinobiz11]

Great article so far. Very long though, must get back to homework lol.

 

[glasshalfMD]

I just spent probably 30 minutes of my work day reading this article. And it was well worth every minute.

My 66-year-old grandfather has end stage pancreatic cancer and I just witnessed a weekend of rapid deterioration. I'm not sure if he's going to make it to next weekend. He and my grandmother have been discussing hospice care for a while now - he's had a DNR and an advanced directive in place since before his surgery at the point of initial diagnosis (a year and a half ago). They almost enrolled a couple months ago, but while out to dinner they told me that they decided to postpone it because he didn't think he was ready yet. He was still going to work and had just finally stopped chemo. This morning, hospice nurses were coming to the house. I'll hear all about the visit when I get home, but just reading an article like this has set my mind at ease. Sure, I've known all along that this is their profession and they're most likely good at it (or they would have moved on to something else). Thank you for sharing this article - I'm sending it around to other members of my family as we speak.

 

[jaxasp]

i don't remember when i started but that probably took me an hour, one of the best articles i've ever read though

 

[PennFranklin]

Very good article and definitely very informative for any hopeful young doctor's out there. Very sad to read about some of the younger people in such dire situations though, makes me think what I would do if faced with similar choices...

 

[willen101383]

For the last three years I have worked full time as a blood bank technologist in a long term acute care hospital in Philly. This is a fancy name for a "nursing home for pts too sick to be in a nursing home." Basically when your acute care hospital had enough of you, you were sent to our facility. I would estimate about 2 or 3 out of 50 patients on the unit had any real chance of ever getting better and leaving the hospital. 90 percent are on vents, and never regain consciousness. Lots of cardiac arrests in the field with prolonged down times, yet they are a full code, because the family members cant let go. Infections, infections, and more infections. MRSA in the sputum, MRSA in the urine, Acenitobacter as well. Yet day after day I had to type and screen these patients, and crossmatch unit after unit of blood on them....knowing that these patients will never regain consciousness. In a time where the blood supply is in serious shape...we are wasting units on gomers day after day. It makes me want to vomit. I will never get why these patients are being tortured like this....and I have actually drafted a written will since working at this hospital. This was a great article and something I unfortunately know all too well. 👍

 

[Evergrey]

I'm glad you guys appreciated it 🙂

It was a fairly long read, kept me up past my bedtime last night. In some ways it was hard to read, because of the subject matter, but I thought it was really informative.

I mean, on one level, you just have to wonder -- why aren't people having these conversations? But on the other hand the answer is pretty obvious... death is truly terrifying. I know if I received a terminal diagnosis, I would probably crap my pants.

It is sad though, that so many people and their families don't get a chance to die the way they want to. If I had to die, I'd want to be outside, in a beautiful meadow with the sun shining, and my family all around me. If you are terminally ill and in a LOT of pain, it might be nice to be able to choose, where, how, and when you die. I guess that makes me feel differently about physician assisted suicide in some ways (yeah I know it was not a focus of the article, but I couldn't avoid thinking about it).

I always get really sad when I see chemo patients in the hospital with end-stage cancer who are going through chemo. You can just look at them and see pain in their eyes. I wonder about what they are losing, and what they could gain, by being off of it. Is a couple weeks worth it, in that case? If they are suffering that much?

The most surprising thing in the article for me was that he suggested that medical interventions may not be that helpful for extending a patient's life when the affliction is incurable. I mean, as people involved in healthcare, we have to wonder why we are doing endless procedures, giving limitless drugs, when they ultimately will just compromise quality of life and waste money to boot. I'm really interested in that research he mentioned about figuring out how to combine hospice care with regular treatment, as well as seeing patient outcomes under hospice care as opposed to the "balls to the wall" approach to end-of-life care.

 

[Narmerguy]

I'm glad you guys appreciated it 🙂

It was a fairly long read, kept me up past my bedtime last night. In some ways it was hard to read, because of the subject matter, but I thought it was really informative.

I mean, on one level, you just have to wonder -- why aren't people having these conversations? But on the other hand the answer is pretty obvious... death is truly terrifying. I know if I received a terminal diagnosis, I would probably crap my pants.

It is sad though, that so many people and their families don't get a chance to die the way they want to. If I had to die, I'd want to be outside, in a beautiful meadow with the sun shining, and my family all around me. If you are terminally ill and in a LOT of pain, it might be nice to be able to choose, where, how, and when you die. I guess that makes me feel differently about physician assisted suicide in some ways (yeah I know it was not a focus of the article, but I couldn't avoid thinking about it).

I always get really sad when I see chemo patients in the hospital with end-stage cancer who are going through chemo. You can just look at them and see pain in their eyes. I wonder about what they are losing, and what they could gain, by being off of it. Is a couple weeks worth it, in that case? If they are suffering that much?

The most surprising thing in the article for me was that he suggested that medical interventions may not be that helpful for extending a patient's life when the affliction is incurable. I mean, as people involved in healthcare, we have to wonder why we are doing endless procedures, giving limitless drugs, when they ultimately will just compromise quality of life and waste money to boot. I'm really interested in that research he mentioned about figuring out how to combine hospice care with regular treatment, as well as seeing patient outcomes under hospice care as opposed to the "balls to the wall" approach to end-of-life care.

Well, to his point, there is always something that could be done, even if it's not much. If the patient wants to know ways they continue to fight the fight, there's no guarantee that these low-probability treatments won't work for them...fighting for the tail end of the curve like he mentioned. I imagine it's hard for the doctors to tell patients that the chances are too small to be worth it...I imagine it would be for any human. It's a lot of responsibility that we're placing on these doctors.

 

[Nefertiri]

This article was wonderful! My mom is an LTAC nurse and has boundless stories about terminal patients and end of life issues addressed in article.

I always wondered how I would feel about being the physician pumping my patients up on morphine and attaching them to tubes and vents when all that develops are bed sores and familial rifts. This article has eased my fears with the premise of the end of life disscussion, which is seemingly invaluable.

Thanks OP!

 

[Nefertiri]

Well, to his point, there is always something that could be done, even if it's not much. If the patient wants to know ways they continue to fight the fight, there's no guarantee that these low-probability treatments won't work for them...fighting for the tail end of the curve like he mentioned. I imagine it's hard for the doctors to tell patients that the chances are too small to be worth it...I imagine it would be for any human. It's a lot of responsibility that we're placing on these doctors.

It is a lot of responsibility, but that is part of the job! Imagine seeing the patient you're fighting for decline to a place of living death with the family looking on in despair. It seems better to admit that the end is too close for any treatment to be beneficial, and concentrate on keeping the patient comfortable - something the patient and family will applaud you for in the end.

 

[delhies]

That is a great article for the future oncologists to read.

It's a great read, anyway. It does show a lot of what we will have to deal with in the future.

 

[45408]

It drives me crazy how many physicians aren't willing to tell patients or their families that they are dying (or don't realize that the patient is trying to die). Putting an 80-year old patient on dialysis after a huge stroke is just madness.

 

[jdh71]

damn fine article

everyone interested in medicine should read this

 

[tweek125]

it sort of reminded me of Brave New World, where children are exposed to death early and conditioned to embrace it instead of fear it. that book is also a great read.

 

[eldoctor]

There was one person who was disturbed by this, though, and who finally decided to intercede—Chuck Morris, her primary physician.

I have to admit when I read this I thought it was a joke, until I realized his name is NOT Chuck Norris.

I have more to say about the article, which I will add later after some errands.
​

 

[Hoody]

I'm an ICU nurse working with Pts who have high comorbities (read, low outcomes). I see the struggle with this all the time...and the sad thing is that DNR/DNI's can be easily overturned by family members after the Patient has lost the ability to decide.

medicine is tricky. and lay people have no clue, really. its only going to get worse as time progresses IMO.

 

[cliffhuxtableDO]

i read the article earlier today. it was a great read. everyone going into medicine should read this and take it to heart.

 

[no beans]

Excellent and thought provoking article. It made me think there should be a course about this in every medical school,maybe even a short rotation with a hospice team. It seemed obvious to me that this is an uncomfortable topic not only for affected patients and families, but also physicians who feel unprepared to handle these situations in some circumstances. I feel it is necessary to learn how to have these conversations with patients and families in a respecting and responsible way. How else can one be adept at this unless one has had the time to think through many of these situations before they present themselves and have garnered advice from professionals who deal with this regularly?

I had lots of thoughts while I was reading this. After all, patients come to their doctors for help, so it seems only logical to offer treatments as they pin their hopes on you. How can you ever burst that bubble of hope, knowing there's that long skinny tail to the right they've been researching? With every treatment offered that bubble is created again. Not only that, but I can imagine that one might come to feel it is one's responsibility to keep coming up with treatments .... almost a catch 22.

I was really captured by Sara Monopoli and her predicament. It reminded me a little of my mother's experience with cancer. When one has a young child (or children), you feel such an incredible responsibility to be there for them. Somehow, it seems that tiny person is counting on you, and no one else will do, so you just want to be there for as many important milestones as you can. I was in middle school when my mother was diagnosed with cancer. She told me once that her main goal was to be around until my sister and I graduated from high school. She was willing to go through anything for the hope of being here till then (which she was and still is, thank goodness). I can't help but think this was Sara's driving force as well.

Atul Gawande's writing style is very engaging, and I really need to read some of his books considering how much I enjoyed this article. The article also made me think about volunteering at a hospice. Sorry for the rambling, I'm tired tonight.

 

[loveoforganic]

Very good read.

 

[georgearms]

There was one person who was disturbed by this, though, and who finally decided to intercede—Chuck Morris, her primary physician.

I have to admit when I read this I thought it was a joke, until I realized his name is NOT Chuck Norris.

tehe

 

[Cleavername]

It drives me crazy how many physicians aren't willing to tell patients or their families that they are dying (or don't realize that the patient is trying to die). Putting an 80-year old patient on dialysis after a huge stroke is just madness.

honestly has its draw backs u know.

it makes no difference to the doctor whether he/she tells the truth or not, but its the patient tho, thats a different story.

 

[boaz]

Excellent article. Gawande is brilliant!

 

[aesculapian]

I'm bumping the thread because this was such a great, thought-provoking, interesting article and I hope more people get a chance to see it.

It does seem like a waste that so much money goes to machines that are ultimately useless for patients who are already on their deathbeds. If you're a patient and you're unconscious, will it make a difference if you're breathing or not? Probably not, but I guess that's why it's usually the families who keep their loved ones alive and can't let go.. I hope I'm not sounding too harsh or cold. It's just if I was a patient I wouldn't want to go that way-- basically dead, even before the time of death is called. But I know it must be so heart-breakingly hard for a parent/child/husband/wife to end their loved one's life.

Also, I completely agree with what no beans said:

It made me think there should be a course about this in every medical school,maybe even a short rotation with a hospice team. It seemed obvious to me that this is an uncomfortable topic not only for affected patients and families, but also physicians who feel unprepared to handle these situations in some circumstances. I feel it is necessary to learn how to have these conversations with patients and families in a respecting and responsible way. How else can one be adept at this unless one has had the time to think through many of these situations before they present themselves and have garnered advice from professionals who deal with this regularly?

 

[cliffhuxtableDO]

bump. just a good article more people should read.

 

[Playa]

So many people are desperate for a CURE cuz people are afraid of death and do not get it that sometimes there is no CURE just making them comfortable and relieving symptoms to the best of our ability. We all are afraid of death even if we deny it but ultimately death is part of the cycle of life. When it comes is to be determined but it will come at some point in time and it is always hard for people to let go when it is their loved one for obvious reasons.

This.

This article was fantastic, Gawande never disappoints. Although hospice care does seem a viable option for terminal cases, and much less of a financial burden on the one's supporting them, people are naturally emotional beings. If dealing with cancer and other diseases, hospice is going to be a last resort for the loved ones who are supporting the patient. It is sad in some ways to see people die and watch their loved ones suffer emotionally and have the burden to pay off $50,000. Healthcare should take this into account.

 

[Algophiliac]

This article brings up the same point that is brought up by people who are trying to keep their loved ones alive through tubes when they are in coma. Problem is not just physicians but really patients and patient families. patient families never want to let go even when there is virtually no chance of bringing back their loved one to life.

Honestly, I think doctors should have the responsibility of educating the patients in this situation, emotionally and mentally. It is a very different issue when the person in the bed is your loved one, your family member, or your friend, or whatever. This is more than "letting go" to some people--the person is technically alive until you request the plug pulled. Everyone in this situation would like to know they are doing the right thing on all mental levels, but that may just be me...but I don't think this is a decision a doctor should let patients doubt, then or later.

Leaving patients on the tubes and machines is more than just a waste of money, as some of you decided to mention here. It's a waste of...well, hope. Every moment of someone wishing the individual would come out of the coma is a moment they are not moving on, not accepting the situation, not living in reality...and I would like to know, for example, if the chances of survival are 97%, and even that not in a timely manner and with numerous mental damages, because then the right decision is obvious.

And, I agree with Atul Gawande. I have actually read numerous books from physicians concerning the proper way to treat patients who are terminal, and it seems there are numerous points of agreement.

 

[yankeesmed]

i don't remember when i started but that probably took me an hour, one of the best articles i've ever read though

Then you must read "Better" and "Complications" by the same author. Complications is much better than Better.

 

[eablackwell]

Then you must read "Better" and "Complications" by the same author. Complications is much better than Better.

I am in the middle of Complications at the moment, and when I saw this article was written by Gawande, I decided to settle into it immediately.

It did not disappoint. I agree that it is very long, but it's worth it, if for nothing more than getting to the Custer/Lee analogy.

When I was 9 I helped my mother care for my grandmother as she struggled with end stage ovarian cancer. I remember how unable to let go the family was and the defeat in my mother's eyes when the family allowed hospice to step in all too late to save any quality of life. She died on my 10th birthday, and no matter how hard I try to think of the years when she was well, all I ever see is her in those final weeks. I agree wholeheartedly with the point that Gawande is trying to make, but I understand it's not easily approachable.

Sorry for the long post. Loved the article. A definite must read. 👍

 

[supercoiled]

Very well written. Atul Gawande brings across the dilemma with anecdotes and stories which makes his writing captivating. While death is often inevitable, the decision about how the patient wants to live the rest of their life, and the quality of life they want, has to be thier own. They have to be told the full truth of their diagnosis, but if they want to fight they should because miracles do occasionally happen.