How Doctors Die

[Mormon Red Death]

Interesting article on end of life care. I've been trumpeting for a while about Hospice care as something that makes sense financially for the country. This piece explains why it makes sense in other aspects.

[ERCougar]

Great article--thanks for posting.

End-of-life care is one of the most misunderstood aspects of our system. The Republicans' latest "death panel" propaganda scare certainly didn't help. In my experience, decisions to pursue what I see as futile efforts stem from a combination of unrealistic expectations, guilt, and ultimately, fear. When I inform patient families that the best outcome we're hoping for in continuing CPR is a vegetative state, their attitudes change dramatically. As the author points out, a good outcome from CPR is extremely rare, and usually only after conditions that are quickly reversible. Outside of my field, long ICU stays typically end badly as well.

I had a patient last weekend whom I told would likely be diagnosed with multiple myeloma, a condition that in her case would likely kill her within a year (medical details if you're interested--basically, tons of lytic lesions in her skull and vertebrae). She was in her late 50s and reasonably healthy otherwise. It made me wonder what I would do in her shoes, and I can't say that I wouldn't just skip treatment and find a way to die gracefully. But I also wonder if my family would let me do that. Breaking Bad comes to mind.

[LA Ute]

Great article, I've been sending it around since I saw it here.

I've forgotten where I saw the data, but I think something like 80% of Medicare funds are spent on final ilnesses. Mind-boggling, when you think about it. Kind of the elephant in the room in health care reform debates.

EDIT: I was off, but the point remains:

The Centers for Medicare and Medicaid Services estimate that 5% of the beneficiaries who die each year take up 30% of the $446-billion annual Medicare budget. About 80% of that money is spent during the final month, on mechanical ventilators, resuscitation and other aggressive life-sustaining care. Often, the aggressive steps taken to save someone's life are futile. A 2009 study published in the New England Journal of Medicine found that just 18% of adults older than 65 who received cardiopulmonary resuscitation in the hospital survived the procedure long enough to be discharged. In addition, researchers found the procedure in some cases prolonged patients' suffering.

[UtahDan]

One of the most thought provoking things I have read in a long time. Thanks.

[ERCougar]

The Hitchens article that woot linked is relevant here:

http://www.vanityfair.com/culture/2012/01/hitchens-201201

[CardiacCoug]

The Centers for Medicare and Medicaid Services estimate that 5% of the beneficiaries who die each year take up 30% of the $446-billion annual Medicare budget. About 80% of that money is spent during the final month, on mechanical ventilators, resuscitation and other aggressive life-sustaining care. Often, the aggressive steps taken to save someone's life are futile. A 2009 study published in the New England Journal of Medicine found that just 18% of adults older than 65 who received cardiopulmonary resuscitation in the hospital survived the procedure long enough to be discharged. In addition, researchers found the procedure in some cases prolonged patients' suffering.

The problem with data like this is there is no way to determine a priori which 18% of people will survive and walk out of the hospital. You only perform CPR on people who are dead. So if your wife was dying suddenly in the hospital and getting CPR and you were told she only had an 18% chance of being able to go home, would you just tell them to stop because it is costing the USA too much money? I wouldn't.

I probably see 2 or 3 people every month in clinic who are living a normal life who survived an in-hospital or out-of-hospital cardiac arrest. One of my patients got CPR for 10 minutes on I-15, CPR for another 10 minutes in the ER, a few stents, and he is now totally back to normal.

Clearly there are other cases when the odds are very low that people will survive (underlying cancer, etc.) and I think hospice is great and definitely the way I would want to go. But sure we would all want to limit the cost of "end of life care" --unfortunately it only turns into "end of life care" retrospectively.

A 90-year old lady with a hip fracture may be statistically in the last 6 months of her life -- do you put her on hospice and let her die or do you operate and fix the hip and give her a chance to be one of those people who beats the odds and lives 5 more good years? I don't think anybody wants the government making that decision for everybody.

I love how number crunchers (not you, LA or anybody else here) love to rail against end of life care when they have no experience with how the end of life care actually happens. There is a lot of uncertainty in all these decisions and I am continuously surprised at the people who have amazing recoveries against all odds.

[ERCougar]

The problem with data like this is there is no way to determine a priori which 18% of people will survive and walk out of the hospital. You only perform CPR on people who are dead. So if your wife was dying suddenly in the hospital and getting CPR and you were told she only had an 18% chance of being able to go home, would you just tell them to stop because it is costing the USA too much money? I wouldn't.

I probably see 2 or 3 people every month in clinic who are living a normal life who survived an in-hospital or out-of-hospital cardiac arrest. One of my patients got CPR for 10 minutes on I-15, CPR for another 10 minutes in the ER, a few stents, and he is now totally back to normal.

Clearly there are other cases when the odds are very low that people will survive (underlying cancer, etc.) and I think hospice is great and definitely the way I would want to go. But sure we would all want to limit the cost of "end of life care" --unfortunately it only turns into "end of life care" retrospectively.

A 90-year old lady with a hip fracture may be statistically in the last 6 months of her life -- do you put her on hospice and let her die or do you operate and fix the hip and give her a chance to be one of those people who beats the odds and lives 5 more good years? I don't think anybody wants the government making that decision for everybody.

I love how number crunchers (not you, LA or anybody else here) love to rail against end of life care when they have no experience with how the end of life care actually happens. There is a lot of uncertainty in all these decisions and I am continuously surprised at the people who have amazing recoveries against all odds.

Cmon really? There's plenty of stuff to predict this--witnessed arrest, age, cardiac history, quality of CPR, etc. Yes, there are surprises, but they're few and far between. I can tell from the ambulance call what kind of chance we have. The last thing our system needs is people expecting more CPR miracles (incidentally, the number who actually walk out of the hospital is much, much lower than 18%).

I'll agree with you on a lot of the other stuff, although there are plenty of prolonged ICU stays that could be avoided by a rational discussion of outcome possibilities.

[ERCougar]

The thing that's been on my mind ever since the multiple myeloma patient that the Hitchens article alludes to is how poorly patients are educated about their options. Hitchens wonders aloud if he had known about the potential side effects if he would have pursued treatment (and one certainly wonders why he did...). Death is a part of the life cycle, yet it's almost programmed into our system that you HAVE to avoid it, no matter the cost. Will anyone offer my patient the option of simply doing nothing? Will the patient's family allow it? I'm not so convinced that either of these questions can be answered affirmatively.

[CardiacCoug]

Cmon really? There's plenty of stuff to predict this--witnessed arrest, age, cardiac history, quality of CPR, etc. Yes, there are surprises, but they're few and far between. I can tell from the ambulance call what kind of chance we have. The last thing our system needs is people expecting more CPR miracles (incidentally, the number who actually walk out of the hospital is much, much lower than 18%).

I'll agree with you on a lot of the other stuff, although there are plenty of prolonged ICU stays that could be avoided by a rational discussion of outcome possibilities.

Sure there are ways to risk stratify people who have arrested, but you don't have all the data when someone arrests, correct? All the data become available retrospectively. If your point is that more people should be DNR and on hospice (those with cancer, etc.) then I completely agree.

You're not saying you would be confident making an absolute decision to withhold therapy based on the ambulance call and patient's age, correct? There is uncertainty and people have surprised the hell out of me in the past.

There are impressive recoveries -- all kinds of people are walking around with tracheostomy scars, meaning they were probably intubated in an ICU for at least 2 weeks.

You look at the thousands of people walking around with heart transplants, most of those people have had weeks of ICU care, hundreds of thousands of dollars in medical expenses. They would all certainly be dead and after weeks if not months of ICU time a lot of them are doing great.

[ERCougar]

Sure there are ways to risk stratify people who have arrested, but you don't have all the data when someone arrests, correct? All the data become available retrospectively. If your point is that more people should be DNR and on hospice (those with cancer, etc.) then I completely agree.

You're not saying you would be confident making an absolute decision to withhold therapy based on the ambulance call and patient's age, correct? There is uncertainty and people have surprised the hell out of me in the past.

There are impressive recoveries -- all kinds of people are walking around with tracheostomy scars, meaning they were probably intubated for at least 2 weeks.

You look at the thousands of people walking around with heart transplants, most of those people have had weeks of ICU care, hundreds of thousands of dollars in medical expenses. They would all certainly be dead and after weeks if not months of ICU time a lot of them are doing great.

No, I would never withhold care based on an ambulance call--I was simply making a point. If anything we overtreat these in the ER, which can financially devastate people, and for no real benefit. Like I said, when families hear numbers and possible outcomes--the ones that we know but don't necessarily share--their decision making changes significantly.

I'm also not talking potentially reversible conditions (i.e. what a heart transplant would treat). You can't tell me that you haven't rounded on vegetables in the ICU as a whole team of doctors simply waits for them to die. Even if there is a very slim chance of recovery, don't you think the family deserves to know how slim that chance is before they're riddled with huge medical bills? Don't you think the payor should consider these chances before they throw tens or hundreds of thousands into the treatment? Sure, surprises happen, but risk stratification is simply necessary when dealing with finite resources.

I'm not advocating putting a price tag on someone's life (well, I guess I am, to some extent), nor would I ever advocate anyone but patients and their families making the ultimate decision--I just think that people need to be made more clearly aware of options, including the one to gracefully die. As the article points out, the informed decision makers are making different decisions than the relatively uninformed ones, which to me indicates a disconnect.

[doctorcoug]

.

I probably see 2 or 3 people every month in clinic who are living a normal life...

One of my patients got CPR for 10 minutes on I-15, CPR for another 10 minutes in the ER, a few stents, and he is now totally back to normal.
.

I respect your clinical expertise and training. Please dispense of the hyperbole. You know as well as I that these patients are never "normal" again. Life dramatically changes IF you survive an arrest.

[CardiacCoug]

I'm also not talking potentially reversible conditions (i.e. what a heart transplant would treat). You can't tell me that you haven't rounded on vegetables in the ICU as a whole team of doctors simply waits for them to die. Even if there is a very slim chance of recovery, don't you think the family deserves to know how slim that chance is before they're riddled with huge medical bills? Don't you think the payor should consider these chances before they throw tens or hundreds of thousands into the treatment? Sure, surprises happen, but risk stratification is simply necessary when dealing with finite resources.

Sure, we deal with this all the time and I always try to take the pressure off of families by saying that all 4 of my grandparents were on hospice before they died and that most people wouldn't want to be on indefinite life support with poor quality of life. I've even said things to patients like "Most doctors and parents of doctors don't die in an ICU -- they die at home with hospice, because it's a much better death."

Part of the problem is that most docs tend to remember the improbable successes (the people in their 80s who had complete recoveries from the brink) really well -- those are the types of people I think about and the results I usually hope for in these cases, even while preparing patients and families for the worst.

[CardiacCoug]

I respect your clinical expertise and training. Please dispense of the hyperbole. You know as well as I that these patients are never "normal" again. Life dramatically changes IF you survive an arrest.

You're saying nobody has ever survived a cardiac arrest (either out of hospital or in the hospital) to live a normal life with a subsequent normal IQ, normal brain functioning, gone back to work as an accountant or whatever?

Maybe I misunderstand you, but those cases happen all the time. I wouldn't think a family practice resident would be involved in very many of those cases, though, so no big deal.

[CardiacCoug]

I respect your clinical expertise and training. Please dispense of the hyperbole. You know as well as I that these patients are never "normal" again. Life dramatically changes IF you survive an arrest.

39% of people survive V-fib arrest and leave the hospital neurologically intact. Quality of life similar to general population for those under 65, mildly decreased for those older than 65.

http://www.ncbi.nlm.nih.gov/pubmed/15071386

Quality of life for survivors of cardiac arrest is similar to general population:

http://www.ncbi.nlm.nih.gov/pubmed/12826637

No difference in quality of life between survivors of out of hospital arrest and controls:

http://www.ncbi.nlm.nih.gov/pubmed/11947973

[hostile]

This is a pretty big issue in my field as I see several "hip" fractures on a yearly basis. National statistics would indicate that the 1 year mortality for these fractures, in patients over 50, is around 30%. Fixing them almost always requires surgery, 3-5 days in the hospital (if there are no problems), and a lengthy rehab stay. Unfortunately, the alternatives to not fixing them are pretty miserable as well. I have had a few patients and their families who have chosen hospice care in the face of a hip fracture. In certain situations I think it is a great option and probably gets underutilized.