The chaos of a code blue // The perverse triumph of resuscitation // The ensuing coma // Other measures that don’t allow nature to take its course
Death: A Peaceful Passing
William Blake/Art Resource
He died before / coronary care / Before the defibrillator / Before lidocaine / Monitors / Before intensive care / nurses. / They put him in / an oxygen tent / They made the diagnosis / just for show / They hoped the best for him. / We let him go.
So wrote the physician-poet John Stone in “Spiritual,” a lamentation that technology hadn’t yet advanced sufficiently to save his father in 1954. Yet that very technology, say these three physicians, can stand in the way of a peaceful, dignified death, because of the physical suffering it can cause and the glimmer of false hope it provides patients, doctors and their families. Ken Murray, a retired clinical assistant professor of family medicine at the University of Southern California, explains why physicians, who routinely see “bad deaths,” typically refuse heroic measures for themselves; Danielle Ofri, a clinician at Bellevue Hospital and editor-in-chief of Bellevue Literary Review, tells a story that exposes the messy truth of resuscitation; and Charles Bardes, associate dean of Weill Cornell Medical College, considers what it means to let go.Death of a Doctor
By Ken Murray
Years ago a highly respected orthopedist (and my mentor, incidentally) found a lump in his stomach. He was diagnosed with pancreatic cancer by one of the best surgeons in the country, who had developed a procedure that could triple a patient’s five-year survival rate—from 5% to 15%—albeit with 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 spent the time with family, and 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—though not like the rest of us. What’s unusual is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they understand 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. But they know the limits of modern medicine. They want to be sure, when the time comes, that no heroic measures will be taken. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me that if you find me like this, you’ll kill me.” 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.
How has it come to this—that doctors administer so much care they wouldn’t want for themselves? In some rare, unfortunate cases, unethical doctors use the fee-for-service model to do everything they can to make money. More commonly, they are fearful of litigation and do whatever they’re asked to avoid it.
One of my patients was a 78-year-old man who had been ill for years and had undergone more than a dozen major surgeries. He told me he never wanted to be placed on life support machines again. Then, one Saturday, he suffered a massive stroke and was taken to an emergency room unconscious, without his wife. In Jack’s worst nightmare, doctors put him on life support. 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.
One of the nurses, I later learned, 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. 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 wishes, prolonging his suffering a few more weeks. I would even have made a little more money, and Medicare would have ended up with a $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.
Except, that is, when they are the ones being treated. They know all too well the consequences. Almost anyone can find a way to die in peace at home, where 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.
Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure caused by lung cancer that had migrated to his brain. We learned that with aggressive treatment, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me, and we spent the next eight months having fun together like we hadn’t had in decades. We went to Disneyland, his first time, and we hung out at home. He was very happy to just watch sports on television and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital food. He had no serious pain, and he remained high-spirited.
One day, Torch didn’t wake up. He spent the next three days in a comalike sleep, 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 physician, but he knew he wanted a life of quality, not just quantity. As for me, my physician has my choices. 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 physicians.