> 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.
This point has been made by many medically trained people over decades. It's a very energetic intensive process, it cracks ribs. If it's not done promptly the brain has been starved of oxygen.
While I understand people not wanting to drag politics into everything I invite you to think about this and the situation of the senior senator for Kentucky.
> Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack... He explained to me that he never, under any circumstances, wanted to be placed on life support machines again.
> 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.
It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
I'm a physician, an old one. We're lucky to live as long as we do, but life will end. The article emphasizes the value of dying peacefully. Sure, that's how we want it to be, but we have to make it known to assure it goes that way.
Don't know what happens elsewhere, but every time I see a doctor someone asks if I have a signed, notarized directive. Yes, I've done that, but so should everybody else concerned about the issue.
I have asked aged patients the same question. More than not the answer is "no". Why haven't you? Various versions of "on my list of things to do". We can't really predict future events, in our own interests best to be prepared. Some will take the hint, more than not, people procrastinate.
At least I've done what I can do, but we can't save people from themselves. Maybe people in healthcare are more aware of what's at stake, but everyone has the option to make it as clear as possible their wish (no, their demand) to die in peace.
Are you a youngish person (<60 yrs) ? If so then this article probably isn't meant for you. This is more meant for the thousands of elderly that get subjected to needless procedures in ICU when their chances of survival are already low. I can recount them from experience of working with people who administered them. This is just the case of American medicine. And in many other countries doctors wouldn't feel pressured to do this.
Last week one of my patients with preterminal NYHA Stage IV cardiac failure looked into euthanasia.
He found predictably that it is now legal in my country but takes months and formidable legal resources to obtain it. Legalisation of euthanasia has, as everyone in the field warned multiple times, made it much harder to obtain and now requires a lot of time, effort and money.
The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it. The potential legal penalties for not getting the paperwork right, include loss of employment, deregistration and homicide charges. So now virtually no doctor wants to be involved for any amount of money.
So I told him how to contact the local palliative care unit when he decides to die, gave him documentation attesting to his preterminal , incurable status and taught him the magic words to almost instantly access that terminal, euthanising, life ending dose of mist. morphine...
"I have breathlessness and bone pain"
Also told him never again to say the word "euthanasia" to anyone, unless he wants a ride on the endless merry-go-round of legal paperwork.
Placing the hands in the abhaya mudra is optional...
> The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it.
That sounds like the actions of a politician who wants to claim they are for something while secretly trying to destroy it. It doesn't seem "well meaning" to me.
That's what the US Republicans did to the ObamaCare act.
This article is making a LOT of "convenient" assumptions.
For all we know, the more likely scenario is that Charlie, like a sizeable percentage of his doctor peers, was burnt out, tired, and depressed, did not really have an overwhelming (some might say "healthy") desire to survive (in fact, perhaps quite the opposite), and saw the cancer as a non-undignified quick "way out".
Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
I have no objection regarding the choice he made, but let's not glorify it as the "natural" thing to do either. This narrative is harmful to people who "do" desire to survive but are scared, which may then prevent them from making a dispassionate decision regarding their care.
Why do you think this was basically a form of suicide?
Pancreatic cancer still has a dismal "survival" rate, and I hesitate to even call it "survival" as it's more a matter of not having died yet. He's seen what chemotherapy does to patients, he knows it's trading the horrors of chemo for a bit longer life. That article is 10 years old--pancreatic cancer is still very deadly. No reprieve was coming down the road.
I'm not necessarily arguing it was a form of suicide (or blaming the victim, as it were).
I'm arguing that the impetus to prolong life is generally a very strong and biologically ingrained urge rather than the result of cold rational thought, and therefore in general such rational thought is often predicated on having lost the biological imperative to some extent (e.g. through a mental health process).
And secondly, the "danger" I'm cautioning against is that this narrative that glorifies rejecting treatment is usually painted as "horrible chemo" vs the implicit scenario of dying peacefully in your bed. But this is not the case, cancer can have horrible symptoms, typically excruciating pain. Chemo is often performed exactly in order to control those symptoms by shrinking the cancer, even if prognosis of survival is poor. There's a reason hospices exist, and it's not because people are ignorant or cowardly and afraid to die in a dignified manner and choose horrible chemo instead of quietly dying in their homes.
In fact, one thing one might want to consider here is that, as a doctor, he may have had easier access to morphine, and this may well have influenced the decision.
> For all we know, the more likely scenario is that Charlie, like a sizeable percentage of his doctor peers, was burnt out, tired, and depressed, did not really have an overwhelming (some might say "healthy") desire to survive (in fact, perhaps quite the opposite), and saw the cancer as a non-undignified quick "way out".
Why do you consider it "more likely"?
> Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
You are suggesting that majority of doctors are depressed with suicidal ideation (hence "more likely")? Care to provide a link to research/data?
It was widely known that doctors are at a considerably increased risk when I was studying medicine, enough to warn us and have professional wellbeing modules in the curriculum. Plus, it's a special population in having significantly different access to relatively covert means, making it more likely to go through with said ideation.
I have seen academic references in the past confirm it. I'm not about to waste time on a scholar deep-dive just to defend my comment but I'm sure you'll find such references easily if you look. Having said that, if "you" have time and you do decide to look and find conflicting evidence that you care to share, I'd be interested to hear more.
> You are suggesting that majority of doctors are depressed with suicidal ideation?
No. I'm suggesting they rank among the highest in occupational risk. In Bayesian terms, the difference between the two is the distinction between a prior and a posterior statement.
> Why do you consider it more likely?
Because, subjectively, the likelihood (low drive for survival given mental disease) should be overwhelmingly higher than the prior (low drive for survival given average person) in this case. Hence more likely.
As a doctor, I think we are prepared for our own death (not so much for illness though). Especially during the last days or months we know exactly what's happening. I agree that the less-care-but-less-side-effects way is chosen much more often by doctors for themselves and their close relatives (I personally administered to my mother opioid to accelerate death due to terminal cancer a couple of days before the expected end that would be tortuous).
For my end stage patients I advise full palliative analgesic and sedative therapy but usually against futile chemos and intubations. There is a discussion where ICU doctors and oncologists have to take part.
> 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 cardiopulmonary resuscitation (that’s what happens if CPR is done right).
I have been seeing so much anti-LUCAS-machine content on the internet lately; it is far too prevalent to be anything but an astroturfing campaign. From whence this meme?
I recently read the book Being Mortal by Atul Gawande, a doctor. He emphasized how terminal care should focus on quality of life instead of attempting to prolong it and making it awful.
Here in the UK there is an ongoing debate happening more or less behind the scenes around the language that should be used for families of patients nearing end of life. The standard question is: Should we "do everything possible" to keep someone alive? The proposed better question is: Should we "allow natural death"? Any doctor understands intimately that these two questions are equivalent. Understandably, the average person doesn't. Why wouldn't you "do everything possible"? In most of these conversations the argument against just doesn't come up.
I really don’t agree here. The focus should be on combating the observational bias that is the cause of these decisions. The doctors remember the “futile” cares for the patients where it had the worst results. We’re wired to concentrate on the negative outcomes, and doctors are bathing in it.
My mother died last month,I have seen that same costly futile care before when it was performed on my father two decades before, but we had no choice. Both were injected with a dozen drugs syringes and perforated with tubes, hooked up to machines.
Although I am somewhat healthy, yet looking at rocking 60 made me contemplate and feel contentment just upon reading about psilocybin for patients dealing with life-threatening diagnoses, end-of-life anxiety (plus a dozen documentaries and 2 on Netflix). Learning about it has offered me relief and lasting drop in existential distress, especially as it helps melt the ego into everything.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9833165/
Last year, my mom was diagnosed with Stage 4 cancer. My family largely agrees with this article: treatment was a mistake and likely worse than the disease (bar palliative care and a stent).
The headline we used in cancer education is about 38% of cancer cases are likely caused and perhaps preventable by modifiable lifestyle factors: Tabbaco, infections, alcohol, UV.
Widespread vaccination (HPV, Hep B/C etc) and precision prevention (genetic counseling and preventative interventions) add another layer of preventative opportunity, and could significantly move the needle inclusive of and beyond/above lifestyle factors.
This leaves a lot of room for change, but requires a changing of economic incentives and cultural factors: which are incredibly slow moving ships.
The next layer is early detection (pre-cancer and early cancer); and technology advancements look promising - multi-cancer blood tests like Galleri and whole-body MRI (Prenuvo, Neko, Midjourney) are scientifically and economically promising, but all commercially ahead of their time.
These two additional pots potentially provide another significant opportunity to reduce the burden where the cost-benefit on personal suffering makes sense.
I’d add as the last personal suffering cost-benefit promising intervention layer targeted immunotherapy (and perhaps to a lesser extent ADCs/smart-bombs), where many patients enjoy results without bearing equal or exceeding suffering. Though with smart bombs, the maths isn’t as convincing, and with both you’re heading into lower odds bets.
Ofcourse, many people are helped by classical chemo, but much of the time (and especially in later stages) you’re hoping to be the exception, and at this point, the population wide experience is in many cancer types net negative.
Many people pin there hopes on this last, narrow category of intervention for breakthroughs; and hopefully they come; but likely this hope, attention and capital is misplaced.
As the article points out, CPR really is oversold. I was a volunteer firefighter and did CPR multiple times, none of those people survived. I watched (and listened) as firefighters did CPR on my wife after she had a massive heart attack, hanging on to some hope but knowing deep down it was futile. But they transported her to emergency anyway.
I watched my father slowly die from sepsis that began with an infection in a toe. Surgery to improve leg circulation failed and his toe was amputated. The antibiotics not only induced the sepsis but led to a C. difficile infection. His mind deteriorated almost overnight. My mom couldn't make the decision to end care and place him in hospice, so the decision was passed to me. He had made his care wishes clear in writing, so while it was a hard decision, I knew it's what he wanted. He died less than a day later.
I'm working on my own care directives so my kids know exactly what to do when it's my time. With luck, they'll be able to ensure those directives are followed.
I thought this was going to speak to the fact of doctors being overconfident in aviation, to the point of crashing more than any other pilot. I see they're still overconfident. :P
I don’t think you have to be a doctor to come to this conclusion. After therapy I realised that the most traumatic thing that took the longest to get over wasn’t watching my Dad die, it was watching him suffer through futile attempts to prolong his life by a few days in intensive care. I wish the doctors had been clearer with us about his chances of survival, I wish we had been brave/knowledgable enough to accept that it was the end and I vow never to put my loves ones through that when my time comes.
I can't say I agree, I think it's more about the death's you're exposed to. Doctors get to experience the full brunt of how the medical system treats patients, the good and the bad. So they opt out of it when it's close to their time so they can die a peaceful death.
But a peaceful death at home is rarely real in my opinion. My father was pretty badly traumatized by his mother who had oral cancer, got a bit through treatment and then refused to continue. His last days with her were spent as she slowly starved and went through terminal dehydration, barely conscious through the drugs hospice used to try and make the passage easier. It's something we tell ourselves post-hoc to try and make ourselves feel better because they died at home with family.
This doesn't mean dying in a hospital is much easier and often family keeps people in a state of semi-torture so that they can have more time. But that I think sometimes we have this 'ideal' of how we want to die, and the reality will always be much messier than that.
I remember reading this article a few years back, and it left an impression enough that I could retell it (but couldn't find it). Which turned out to be helpful, during/after my mother's passing half year ago.
Thanks for sharing it, I can now share it to my siblings. A silver lining that despite the cancer she could leave relatively peacefully.
The article & some comments do make me wonder: my mother refused any medication, including any painkillers, for 6 weeks after terminal diagnosis. Only on her last day, when breathing got painful did she accept a fentanyl patch to be administered. She lost her consciousness a few hours later, and less than a day later her breath. I wonder if it was dosed for that (as some form of mercy)
> 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.
man, what an article. my father's a surgeon, and my aunt was diagnosed with pancreatic cancer recently. he told me he checked the literature to see that there's a very high mortality rate, and seems to have accepted whats to come. but my aunt and her family is doing the "everything" part. I have a feeling that they're resenting my father for not involving as much as they think he should, and I can see from both angles. I have a feeling that my father would also choose the same path of just retiring and patiently waiting to die in a similar circumstance. I wish both him and people who read this comment a dignified and easy end.
37 comments
[ 3.2 ms ] story [ 69.1 ms ] threadThis point has been made by many medically trained people over decades. It's a very energetic intensive process, it cracks ribs. If it's not done promptly the brain has been starved of oxygen.
While I understand people not wanting to drag politics into everything I invite you to think about this and the situation of the senior senator for Kentucky.
> 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.
It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
Don't know what happens elsewhere, but every time I see a doctor someone asks if I have a signed, notarized directive. Yes, I've done that, but so should everybody else concerned about the issue.
I have asked aged patients the same question. More than not the answer is "no". Why haven't you? Various versions of "on my list of things to do". We can't really predict future events, in our own interests best to be prepared. Some will take the hint, more than not, people procrastinate.
At least I've done what I can do, but we can't save people from themselves. Maybe people in healthcare are more aware of what's at stake, but everyone has the option to make it as clear as possible their wish (no, their demand) to die in peace.
This is not abstract for me. I have not one, but two forms of cancer.
Both were considered incurable when I was diagnosed.
Both have treatments now that, IN SOME PEOPLE, lead to remission.
I still don't know which group I am, but I'd be dead from either one by now, if I hadn't elected to treat.
New treatments, for SOME cancers are literally coming out monthly.
So the fact that you can't be cured today, does mean there won't be a better treatment by next year, if you can hang on.
I should find out soon on my more aggressive one. Either way, I plan on continuing to try.
---
How doctors die. It’s not like the rest of us, but it should be
---
Note to submitters: Check the title after submitting. If the HN algorithm mangled it as badly as this one, edit it!
He found predictably that it is now legal in my country but takes months and formidable legal resources to obtain it. Legalisation of euthanasia has, as everyone in the field warned multiple times, made it much harder to obtain and now requires a lot of time, effort and money.
The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it. The potential legal penalties for not getting the paperwork right, include loss of employment, deregistration and homicide charges. So now virtually no doctor wants to be involved for any amount of money.
So I told him how to contact the local palliative care unit when he decides to die, gave him documentation attesting to his preterminal , incurable status and taught him the magic words to almost instantly access that terminal, euthanising, life ending dose of mist. morphine...
"I have breathlessness and bone pain"
Also told him never again to say the word "euthanasia" to anyone, unless he wants a ride on the endless merry-go-round of legal paperwork.
Placing the hands in the abhaya mudra is optional...
That sounds like the actions of a politician who wants to claim they are for something while secretly trying to destroy it. It doesn't seem "well meaning" to me.
That's what the US Republicans did to the ObamaCare act.
For all we know, the more likely scenario is that Charlie, like a sizeable percentage of his doctor peers, was burnt out, tired, and depressed, did not really have an overwhelming (some might say "healthy") desire to survive (in fact, perhaps quite the opposite), and saw the cancer as a non-undignified quick "way out".
Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
I have no objection regarding the choice he made, but let's not glorify it as the "natural" thing to do either. This narrative is harmful to people who "do" desire to survive but are scared, which may then prevent them from making a dispassionate decision regarding their care.
Pancreatic cancer still has a dismal "survival" rate, and I hesitate to even call it "survival" as it's more a matter of not having died yet. He's seen what chemotherapy does to patients, he knows it's trading the horrors of chemo for a bit longer life. That article is 10 years old--pancreatic cancer is still very deadly. No reprieve was coming down the road.
False hope generally leads to inferior outcomes.
I'm arguing that the impetus to prolong life is generally a very strong and biologically ingrained urge rather than the result of cold rational thought, and therefore in general such rational thought is often predicated on having lost the biological imperative to some extent (e.g. through a mental health process).
And secondly, the "danger" I'm cautioning against is that this narrative that glorifies rejecting treatment is usually painted as "horrible chemo" vs the implicit scenario of dying peacefully in your bed. But this is not the case, cancer can have horrible symptoms, typically excruciating pain. Chemo is often performed exactly in order to control those symptoms by shrinking the cancer, even if prognosis of survival is poor. There's a reason hospices exist, and it's not because people are ignorant or cowardly and afraid to die in a dignified manner and choose horrible chemo instead of quietly dying in their homes.
In fact, one thing one might want to consider here is that, as a doctor, he may have had easier access to morphine, and this may well have influenced the decision.
Why do you consider it "more likely"?
> Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
You are suggesting that majority of doctors are depressed with suicidal ideation (hence "more likely")? Care to provide a link to research/data?
I have seen academic references in the past confirm it. I'm not about to waste time on a scholar deep-dive just to defend my comment but I'm sure you'll find such references easily if you look. Having said that, if "you" have time and you do decide to look and find conflicting evidence that you care to share, I'd be interested to hear more.
> You are suggesting that majority of doctors are depressed with suicidal ideation?
No. I'm suggesting they rank among the highest in occupational risk. In Bayesian terms, the difference between the two is the distinction between a prior and a posterior statement.
> Why do you consider it more likely?
Because, subjectively, the likelihood (low drive for survival given mental disease) should be overwhelmingly higher than the prior (low drive for survival given average person) in this case. Hence more likely.
How Doctors die. It’s not like the rest of us (2016) - https://news.ycombinator.com/item?id=28463482 - Sept 2021 (291 comments)
For my end stage patients I advise full palliative analgesic and sedative therapy but usually against futile chemos and intubations. There is a discussion where ICU doctors and oncologists have to take part.
I have been seeing so much anti-LUCAS-machine content on the internet lately; it is far too prevalent to be anything but an astroturfing campaign. From whence this meme?
Although I am somewhat healthy, yet looking at rocking 60 made me contemplate and feel contentment just upon reading about psilocybin for patients dealing with life-threatening diagnoses, end-of-life anxiety (plus a dozen documentaries and 2 on Netflix). Learning about it has offered me relief and lasting drop in existential distress, especially as it helps melt the ego into everything. https://pmc.ncbi.nlm.nih.gov/articles/PMC9833165/
Last year, my mom was diagnosed with Stage 4 cancer. My family largely agrees with this article: treatment was a mistake and likely worse than the disease (bar palliative care and a stent).
The headline we used in cancer education is about 38% of cancer cases are likely caused and perhaps preventable by modifiable lifestyle factors: Tabbaco, infections, alcohol, UV.
Widespread vaccination (HPV, Hep B/C etc) and precision prevention (genetic counseling and preventative interventions) add another layer of preventative opportunity, and could significantly move the needle inclusive of and beyond/above lifestyle factors.
This leaves a lot of room for change, but requires a changing of economic incentives and cultural factors: which are incredibly slow moving ships.
The next layer is early detection (pre-cancer and early cancer); and technology advancements look promising - multi-cancer blood tests like Galleri and whole-body MRI (Prenuvo, Neko, Midjourney) are scientifically and economically promising, but all commercially ahead of their time.
These two additional pots potentially provide another significant opportunity to reduce the burden where the cost-benefit on personal suffering makes sense.
I’d add as the last personal suffering cost-benefit promising intervention layer targeted immunotherapy (and perhaps to a lesser extent ADCs/smart-bombs), where many patients enjoy results without bearing equal or exceeding suffering. Though with smart bombs, the maths isn’t as convincing, and with both you’re heading into lower odds bets.
Ofcourse, many people are helped by classical chemo, but much of the time (and especially in later stages) you’re hoping to be the exception, and at this point, the population wide experience is in many cancer types net negative.
Many people pin there hopes on this last, narrow category of intervention for breakthroughs; and hopefully they come; but likely this hope, attention and capital is misplaced.
I watched my father slowly die from sepsis that began with an infection in a toe. Surgery to improve leg circulation failed and his toe was amputated. The antibiotics not only induced the sepsis but led to a C. difficile infection. His mind deteriorated almost overnight. My mom couldn't make the decision to end care and place him in hospice, so the decision was passed to me. He had made his care wishes clear in writing, so while it was a hard decision, I knew it's what he wanted. He died less than a day later.
I'm working on my own care directives so my kids know exactly what to do when it's my time. With luck, they'll be able to ensure those directives are followed.
https://www.faa.gov/data_research/research/med_humanfacs/oam...
But I wonder... isn't it US specific local trend where medical bill is ridiculous? There is no way ICU cost 10K USD/day... except in US.
But a peaceful death at home is rarely real in my opinion. My father was pretty badly traumatized by his mother who had oral cancer, got a bit through treatment and then refused to continue. His last days with her were spent as she slowly starved and went through terminal dehydration, barely conscious through the drugs hospice used to try and make the passage easier. It's something we tell ourselves post-hoc to try and make ourselves feel better because they died at home with family.
This doesn't mean dying in a hospital is much easier and often family keeps people in a state of semi-torture so that they can have more time. But that I think sometimes we have this 'ideal' of how we want to die, and the reality will always be much messier than that.
Thanks for sharing it, I can now share it to my siblings. A silver lining that despite the cancer she could leave relatively peacefully.
The article & some comments do make me wonder: my mother refused any medication, including any painkillers, for 6 weeks after terminal diagnosis. Only on her last day, when breathing got painful did she accept a fentanyl patch to be administered. She lost her consciousness a few hours later, and less than a day later her breath. I wonder if it was dosed for that (as some form of mercy)
Life imitating Madame Bovary.