Death-denial is something doctors can change

I’m not sure why so many doctors don’t get it.

Death, that is. Where in medical school, or residency, or even in non-medical life, did this many smart people get the idea that death is optional?

Theresa Brown is an oncology nurse and a writer. This weekend, her regular column in the New York Times dealt with the death-denying culture of doctors.

She begins by describing a common scenario of an elderly person suffering at the hands of a doctor who would not give up. Patients with irreversible organ damage do not get stronger in rehab, she explains. Ms. Brown then tells us how earlier palliative care could have helped this man. This didn’t happen because of a knowledge deficit. Palliative care is often mistaken for giving up rather than changing course. In the middle part of her essay, she describes the benefits of palliative care, including the fact that relieving symptoms can actually extend life. The best part of her essay comes at the end when she notes the paradox of doctoring—the charge of keeping patients alive but knowing that we always fail.

“Physicians also need to recognize that there are occasions when the patient’s fate is not, in the end, the doctor’s work. Every patient deserves care on his own terms, for each patient’s life, and death, is his own.”

This seems obvious. Why it is not so in real life baffles me.

I understand that when we are well, it’s normal to want to keep living. No well-person wants to die. It’s even hard to think about dying.

But shouldn’t doctors be different?

We are experts in health and disease. We know that any treatment comes with tradeoffs. Big tradeoffs in the elderly. Chemotherapy kills cancer cells along with normal cells; heart surgery means cutting through an elderly body, and implanting a cardiac device means removing the chance of a painless quick death or extending the lonely road of cognitive decline.

It is our job to see the obvious: No, the emaciated man will not tolerate heart surgery or chemotherapy, and he is emaciated because loss of hunger comes at the end-of-life. Which is normal.

Part of treating people with skill and compassion is having a clear-eyed view that death is normal. Death-avoidance comes with grave costs. The harm inflicted at our hands can be immense. In the elderly and ill, seeing such tradeoffs has never been more important.

There are many things in healthcare that doctors cannot change. Death-denial is not one of them. Here, we have the ability to lead, to affect positive change. All it takes is the strength to step from the crowd, see the obvious, and simply embrace the perspective that both life and death belong to the patient.

JMM

6 comments

  1. Other than the obvious “I’m a doctor and I can save your life” [regardless of the
    quality of that life]……in other words….the amazing hubris of most physicians…

    I offer 2 more:

    1. Money.~ as long as the patient is alive, the doctors, hospitals and “homes”
    can exact huge profits from keeping him or her breathing….

    2. Lawsuits….

  2. Well said. So true. Working in Hospice as a volunteer during Nursing School, we were so frustrated at the doctor’s delayed referral to us when our patients only had days or hours to live. Palliative care can make the difference between a ‘good’ and ‘bad’ death……literally! I consider it one of my joys and duties as a retired NP, to educate our church, community, and nation (to the best of one person’s ability) to find peace in the death process and Hospice does a wonderful job of facilitating that! Thank you Dr. John, for this well written column! I wish it could be front and center NEW YORK TIMES!

  3. Thank you for these thoughtful words. I also really enjoyed the NY Times article. Somewhere we switched from seeing death as a tragedy or a sad event to being a failure. When that happened is precisely when we went off the rails in modern medicine.

    Just to address the first comment, I’m a physician and therefore I must be biased but I don’t think money is a huge factor nor do I think it is lawyers. I think most of these high costs and aggressive care at the end-of-life is driven by scared patients and families and well-meaning doctors, not demanding, litigious patients and money-grubbing doctors. Thus, I think you hit the nail on the head – it is really about accepting dying as the natural end to all life.

    Very nice post – thank you for pushing this message.

  4. Excellent post – an issue that needs to be discussed at many levels.
    I feel that teaching of biology underemphasises greatly one of the central, fundamental concept ( even law if you will ).
    MULTICELLULAR LiFE HAS DEATH WRITTEN INTO ITS SCRIPT.
    The earliest slime moulds that opted for the multicellular life did so accepting the trade off between death for the somatic cells and immortality for the sex cells.
    If this point was understood – doctors can build on it and understand death better and accept its inevitabilty.

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