Dying With Your Stethoscope On

I’ve been mulling over this absolute must-read for some time:

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).

Growing up in a medical family, I can confirm that this is mostly true. I know several medical people who want the last full measure but many more want nothing more than some pain meds. It’s not just doctors either. Rich people die this way too. If they can afford their own in-home nurse, they will go home, make sure they have enough opioids and die peacefully (and cheaply). It’s the ultimate irony of our broken Medicare system that you have to be rich to die on the cheap.

It got lost in all the talk of “death panels”, but end-of-life nonsense is a huge and avoidable contributor to Medicare’s bloated budget. For many people, almost inhuman procedures drag out death for days and tally up hundreds of thousand in costs. You can read personal story in Goidhill’s article, which is still, 2.5 years later, the best thing written about healthcare in the United States.

The thing is, the system is set up this way. In the absence of specific orders, hard coding is the default. Part of it is defensive medicine — although the silly misinformed twats who do their studies of “defensive medicine” don’t include it when they assure us defensive medicine only costs 2% of the bill. Doctors can be sued and even prosecuted for “pulling the plug” if they don’t have legally binding instructions from the patient.

Another part is that if a patient is unable to make decisions, the responsibility falls to the family. And families often choose to go the last full measures since (a) they have trouble letting go; (b) they don’t want to take the responsibility for killing grandma; (c) they often have a poor understanding of precisely what’s involved; and (d) it’s the government’s dime anyway. Unless the patient had legally binding orderes written in advance, they will almost go out in misery.

The thing is, most people don’t want this. But they end up getting it because they don’t know it’s standard. They end up getting it because they left no legally-binding orders. They end up getting it because they didn’t want to deal with the fact that they were going to die one day.

Well, tough. When you’re on the taxpayers’ dime, I don’t think you get the luxury of pretending you’re not going to get sick and die. This is why I support a change to Medicare: to enroll in the system, you must write end-of-life orders. There’s no restriction on what you can do — if you want the last full measure, you can get the last full measure. Or you can hoose, if you want, to get a home nurse and some drugs. But you have to make a decision (albeit one you can revisit if you change your mind).

Over the long haul, this would save the taxpayers hundreds of billions and save millions of people from needless anguish. Just ask the doctors.

What’s stopping it? Mostly, there’d be too much of a political price to pay. The epic brouhaha over Terri Schiavo is too fresh in many minds. Even suggestions of end-of-life counseling brought out cries of “death panels”. And the Democrats are in a glass house, since you can bet the farm they would say the same or worse if a Republican proposed such a thing. And so we sit here, year after year, sending hundreds of thousands of our citizens shrieking into the afterlife while our national treasure burns up.

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  1. hist_ed

    My wife’s grandmother choose when to die. She was a diabetic and her kidneys failed. She spent a few months on dialysis, but hated it (why can’t they figure out how to warm things up on dialysis?). She told everyone she was going to stop and stayed at home. All of her children and most of her grandchildren and great grandchildren came to see her in the two weeks are she made that choice. My second son was about 6 months old and spent a lot of time next to her. His older brother still remembers great grandma. She was reasonably comfortable and lucid to the end.

    Now her husband is dying. He is not lucid but his body is strong for a 96 year old. This combat veteran of World War Two and Korea has to deal with barely being able to function during his best moments. Mostly he is out of it (my wife was with him a few days ago and says all he was conscious of was pain). Yet the hospital, nursing home and VA all want to do everything to keep his heart beating. I really don’t want my kids to see him like this and I’m sure if he was coherent he would agree. I bet if a year ago you had described his condition today to him he would have said “hell no, I don’t want to be like that” but now, even if in a rare lucid moment he indicated he wanted to stop treatment, they probably wouldn’t acknowledge it.

    Sometimes (like grandma) the body goes before the mind. It’s tougher when it is the other way around. Grandpa never wrote out end of life instructions so this parade of pain will likely continue for days or weeks or months. I’ve reiterated to my wife, siblings and oldest child my wishes (it’s in writing, too) if my mind goes and everyone else should too.

    This is why I support a change to Medicare: to enroll in the system, you must write end-of-life orders.

    So, I actually agree with this. No pressure, no counseling, but everyone taking my tax money for medical care should have to write up how they want it to end.

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  2. AlexInCT

    The thing is, the system is set up this way. In the absence of specific orders, hard coding is the default.

    Awesome advice.

    My father in law passed away last year. One of the few people I knew that actually influenced my life. This guy was a real, real good guy. Had a stroke and it hurt him bad.

    He had his papers in order, including a DNR, and told his 6 daughters to celebrate his life, not feel sad he was dying, because he had lived a great life, before he slipped into a coma. Smooth as can be. I wish when my time comes I can do it with that kind of dignity and go quick and painless. Not drag on like some of these horror stories you hear about..

    I have never understood the need to keep people alive that did not want it. I guess the right thing to do is to assume everyone wants to stay alive as long as possible, but when quality of life becomes crap, especially when you are suffering badly, I can not believe staying around longer is such a big deal. I guess the alternative could be worse.

    Have your paperwork in order.

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  3. hist_ed

    Thanks for sharing, hist. Hoping for he best for your wife’s grandfather.

    They took him off breathing support this morning. It probably won’t be long now. I barely knew my grandparents. My mom’s parents were in England and I only met them once. My dad’s dad died when I was young- heart attack when he was flying a small plane. I remember grandma more, but only saw her a few times as she lived in Illinois and I grew up in Seattle. When I married my wife I got to have grandparents that I saw regularly for the first time in my life.

    I just glad that my kids have had so much contact with extended family. Most of mine and all of my wife’s live around here, so they get to grow up seeing them all the time.

    Sorry for getting a little maudlin. It’s a little tough seeing a horrible end like this coming to a guy who fought the fascists up the boot of Italy. Major M.B. Miller fighting his last battle.

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