How Should Doctors Die

The following article by Dr Ken Murray, MD, was sent to me by e-mail from someone for comment.


I was then asked by another e-mailer to comment. Here’s the article by Dr Murray, and my comment. Read on.


How Doctors Die


It’s Not Like the Rest of Us, But It Should Be


by Ken Murray MD


Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.


It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.


Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).


lmost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.


To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.


How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.


To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.


The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.


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.


Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.


Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.


But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.


Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.


We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.


Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

(Ken Murray MD, is a Clinical Assistant Professor of Family Medicine at USC)

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Perry T then asked: “Dr. JB Lim, over to you for further comments”

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Below is what jb lim comment on Dr Ken Murray view, and answer to the question put to him by P Tan:

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jb lim replies:


I think I have said that again and again, and yet again. There is NO cure for terminal illnesses.


Don’t waste your precious time, your money, and your effort with doctors. They CANNOT help you, no matter who he or she is, specialist, super-specialists, or just ordinary doctors.


They (all of them) do not have the answer. They too have to die one-by-one one day. There is completely NO exception for anyone on this earth to escape disease, old age and death.

This is as sure and fixed as the ‘law of the Medes and Persians’ (Esther 1:19).


Disease and death are completely NO respecter of any person, no matter who he is.


In one of my textbooks on medicine, it is very clearly stated there (in the preface itself), this statement:


“Finally, all will die either from accidents, infection, malignancy (cancers), degeneration, or organ failure”


Completely No escape:


There is completely no escape, not even if you have all the money in this world, in a vain attempt to save or prolong your life.


You only add to your own misery to enrich the bank accounts of your specialist doctors instead. Don’t be an ass and an idiot to do that. Just write a will, and leave this world gracefully, and your will shall


Leave everything to your young children or grand children. They are NOT just young, but they are a generation of new people with newer and better genes, facing a new life with better and newer adaptability.


They have a better and a brighter future ahead of them than oldsters. Why not? Why not bow gracefully and give way to them instead of spending all your life savings trying vainly to live beyond what God has ordained for us.


An Experience:


A few years ago I was at an expensive and well-known private hospital to visit my nephew where he was operated by my youngest brother, a former Professor of Heart-Lung and Vascular Surgeon at the University Hospital, University of Malaya, and later a Consultant Cardiothoracic and Vascular Surgeon. He, together with another surgeon operated on my nephew who had cancer of the esophagus.


While waiting outside the operating theater, I saw a huge crowd of Indians of at least 150 relatives waiting and milling around the entire 2nd and 3rd floor, and spilling throughout the stairways of this private medical centre.

They were all waiting to see their relative, a 95 year old lady (granny) who was also warded there for heart, liver, lungs, kidney and other multiple organ failures.


Among the huge crowd of Indian relatives and visitors, were also 5 medical specialists who were relatives of this old lady. The medical specialist relatives of this granny flew in from as far as the UK, Australia and Singapore to see her hospitalized at the hospital.


Multiple Drug Toxicity or Medical Heroism?


While I was waiting for my brother to finish the operation on our nephew, one of their specialists relatives told me they all flew in to help chip in financially to ‘help and save’ their old lady’s life by getting 10 other medical specialists at the hospital to treat her. They told me they were doing their best. Was it a joke they did not want their 95 year old granny to die from multiple organ failure?


I got a shock of my life when I heard this – 10 medical specialists trying to save the life of a 95 year old granny with multiple organ failures, and was in a comma? What were they all trying to do?


I just wonder the amount of drugs she must have been given by all these 10 specialists, each prescribing their own ‘special medicines' or 'specialists medicine' (whatever that is)? That must have been some kind of a record.

That must have accelerated the old granny's liver and kidney failures even faster.


If you are a medical doctor, there is a term we use. We call it iatrogenic disease, iatrogenic death, meaning disease and death caused by doctors themselves.


The Greatest Joke:


I did not know whether to faint on the spot or to laugh when one of their relatives told me – getting 10 medical specialists to 'treat' and to 'save' a 95 year old granny lying in coma with multiple organ failures.


It must be the most ‘fantastic’ medical jokes I have ever heard in my entire 40 years of professional career.


I cannot help saying it again. Five (5) medical specialists’ relatives of this old lady flew in from UK, Australia and Singapore to ‘save’ the life of their 95 year old Indian relative.


They employed 10 more specialist doctors from that private hospital to ‘do the job’. This must be a page taken out from a story book on medical fantasy! Goodness gracious me!


If these relatives were just lay people, I can understand their desperation, but there were 5 medical specialists among the huge crowd of relatives, all there trying to be ‘medical heroes’.


Were these doctors trying to play a game of dice with God?


I think these medical specialists and the granny's relatives were ‘kay po chee’ (busybody) trying to challenge and defying God’s Prescription with their own man-made prescriptions.


Unfortunately God does not play dice. God has a design well formulated for everybody He planted on Planet Earth.


Born Losers with Trusting:


I guess they must have spent tens of hundreds, of hundreds of thousands of ringgit to be ‘heroes’ to enrich the hospital and the other 10 specialists to prolong the misery of this old granny. The 10 specialists and the hospital must be laughing all their way to the bank.


Guess What?


You guessed it. The old lady died the next day.


Guess what also?


My nephew also died three weeks later after being transferred to Sultanah Aminah Hospital in Johor Bharu where it was much, much cheaper for his family.


In fact he got all the treatment completely free at Sultanah Aminah Hospital. But he still died in the end.


Plainly Seen:


We can very clearly see the folly of modern medicine against Nature, and what God has already programmed and prescribed for us.


Whether or not both of them lived another 10, 20, 50, 100 or even another 100,000 years, finally ALL MUST close their eyes throughout all eternity. If that is so, the patient might as well die right away, because none of us will see anything after that!


This is reality, and we, whether doctors, patients or healthy living people just cannot run away.


Before I end a long opinion, let me quote:



• The days of our years are threescore years and ten; and if by reason of strength they be fourscore years, yet is their strength labor (advances in medicine, medical research and in nutrition) and sorrow (disease, sufferings and pain); for it is soon cut off (death), and we fly away (Psalm 90:10)



• Whereas you know not what shall be tomorrow. For what is your life? It is even a vapor, that appears for a little time, and then vanishes away (James 4:14)


Finally,


• Wisdom will multiply your days and add years to your life (Proverbs 9:11)


Losing Battle:


As a former research medical scientist of many matured years, let me harshly without regrets, warn every living person this harsh reality. We are all fighting a losing battle against Mother Nature and disease. We are just bluffing and cheating ourselves.



Being well trained myself, having attended post-doctoral courses in medical statistics and epidemiology, and other in-service courses sponsored by WHO, Ministry of Health at the Institute for Medical Research and elsewhere, I have seen yearly medical statistics on the increasing rise of diseases and mortality, and changing trends of diseases patterns in Malaysia and world-wide.


No Answer:


We just have NO answer how to deal with chronic and degenerative diseases no matter what effort, money and brains for research we put in. We are losing, and losing. We can NEVER beat Nature.


We have NO answer at all with old diseases resurfacing and new ones emerging from nowhere. There they are. That’s it! It’s final!



Limit of Human Life Span:


Scientists tell us clearly our human life span is just 120 years maximum, come-what-may! – Physician or no physician, medicine or no medicine, and all those rubbish stuff.


In fact I have giving two talks so far, entitled:


‘The Biology of Aging: Why we Must Grow Old and Die’


Both of them were given to:


• Members of the Malaysian Senior Scientists Association

• The Academic Staff of the University of Malaya

The lectures were delivered two years ago.


A Hind Thought:


As an amateur astronomer, let me make a simple calculation to show you this reality:


The age of the Universe is estimated to be 20 billion (American billion) or 20 thousand million (20 000,000,000) years or 60 sec per minute x 60 min per hour x 24 hrs per day x 365.25 days per year x (2 x 10 10) years = 6.31152 x 10 17 seconds



Our maximum human life span is 120 years or 60 sec x 60 min x 24 x 365.25 x 120 = 3,786,912,000 seconds.



If 20 billion years were to be telescoped into a 24 hour day (86400 seconds), then 120 years of our lives would be translated into 3,786,912,000 / 6.31152 x 10 17 = 6 x 10 -9 seconds (0.000,000,006) or 600 millionth of one second.



That’s all the life we have on Earth since the birth of the Universe 20 billion years ago, disease or no disease, physician or no physician.


So my advice to doctors and clinicians is: 'Physician heals thyself first'!



Exactly as told to us:


This is exactly what is given in the Bible:


• ‘It is even a vapor, that appears for a little time, and then vanishes away’ (James 4:14).


The Bible is never wrong. It is in perfect conformity with Science.


I hope I have answered P Tan's question.


Take care, and the body will naturally take care of you!


lim ju boo