January 17, 2013 9:55 am
We all have to die at some point. Most of us would prefer for it to be as painless as possible. And yet we can’t seem to let our loved ones go, often prolonging their stay amongst the living for as long as we can.
But what about those who attempt to keep us alive? How do doctors want to die? A recent Radiolab short tackled this very question:
Joseph Gallo, a doctor and professor at Johns Hopkins University…discovered something striking about what doctors were not willing to do to save their own lives. As part of the decades-long Johns Hopkins Precursors Study, Gallo found himself asking the study’s aging doctor-subjects questions about death. Their answers, it turns out, don’t sync up with the answers most of us give.
Ken Murray, a doctor who’s written several articles about how doctors think about death, explains that there’s a huge gap between what patients expect from life-saving interventions (such as CPR, ventilation, and feeding tubes), and what doctors think of these very same procedures.
Essentially, what doctors would want for themselves and what they provide to patient is quite different. They don’t want CPR or dialysis or chemotherapy or feeding tubes—treatments they themselves prescribe regularly.
Atul Gawande, a doctor himself, tackled this same question in The New Yorker two years ago:
These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition—advanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isn’t. So everyone struggles with this uncertainty—with how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly?
And that’s not what doctors should do, Gawande says:
The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.
More often, these days, medicine seems to supply neither Custers nor Lees. We are increasingly the generals who march the soldiers onward, saying all the while, “You let me know when you want to stop.” All-out treatment, we tell the terminally ill, is a train you can get off at any time—just say when. But for most patients and their families this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. But our 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.
Humans aren’t good at dealing with death. We don’t like to talk about it; we don’t like to think about it. We talk a lot about what happens after we die (this Radiolab tackles that question) but in the months or years just before we die, things suddenly get fuzzy and irrational. Michel de Montaigne (whose own story about death is quite interesting) says:
“If you don’t know how to die, don’t worry; Nature will tell you what to do on the spot, fully and adequately. She will do this job perfectly for you; don’t bother your head about it.”
Unfortunately, Montaigne’s Nature does not speak to doctors, or to the non-dying, so we’re stuck floundering until we can cope with death a little bit better.
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