How Doctors Die (2011) | Hacker News Reader

How Doctors Die (2011)

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This has been a pretty controversial article, because the evidence supporting the author's claims is not terribly good. One of his key studies relied on people who volunteered, while in med school, to participate in a study that would continue as they aged and died. It's not hard to imagine this group was more comfortable thinking about mortality than most doctors.

Certainly more doctors than members of the general public have things like living wills that simplify end of life care than the average person, however more people who make as much money and have as much education as doctors also have living wills more often than the general public. I haven't been able to find numbers for doctors compared to, say, lawyers or professors.

There does seem to be a subculture among doctors who are looking into how to die well, and may be better at it and act on their beliefs with greater confidence and urgency than those who don't encounter death as often, but it seems like many, if not most, doctors cling to life and try to delay the inevitable like the rest of us.

For some additional data, see here: https://www.sciencebasedmedicine.org/doctors-and-dying/

>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.

I've had many doctors indicate to me that if they find this on someone coming into the ICU, most hospitals will still attempt to resuscitate.

It's a "damned if you do, damned if you don't" situation. If you don't attempt to resuscitate, the patient's family may sue for letting them die and not attempting resuscitation. Granted, if you do resuscitate, you may be sued by the patient. Most hospitals feel there is far lower risk if they resuscitate, so "NO CODE" or "DNR" tattooed on your chest will likely be ignored.

Yeah, as a former volunteer EMT, I'd like to ask you not to do this. The rules vary by country and by state in the US; e.g. I can tell you that in New Jersey as of 10 years ago, there was a standard document (DNR order) which needed to be signed by the doctor and the patient or the legal guardian, which needed to be available to the EMS crew. In any case, I haven't heard that anywhere, a tattoo or bracelet or necklace is legally sufficient, although it may be in your jurisdiction.

You'd be putting the EMS crew in a very tough spot: believe me, nobody wants to do pointless resuscitations on people who don't want them, but there are usually very specific policies and laws about when an EMS crew can stop or not attempt resuscitation, and if they aren't met, it's really hard for me to see how an ambulance crew can follow your (apparent) wishes.

On a more positive note, I don't think that DNR orders make sense for people without advanced disease, or who are not elderly and in poor health. For the healthier people, an out-of-hospital cardiac arrest is more likely to be caused by something like blood loss in an accident or by electric shock, or by relatively fixable arrhythmias and heart disease. I don't see a reason to prevent the emergency crew and the hospital from giving you a chance.

Would my having the properly signed copy of a DNR on my person at all times (along with some kind of placard to indicate where on my person it is) be sufficient in your opinion?

My opinion is not valuable, since I don't know the laws in your jurisdiction. Since, in order to have a proper DNR order in your jurisdiction, you probably need to talk to a doctor, you should just ask them what the requirements are. Again, in New Jersey, what you say will be sufficient, and you can even have a DNR bracelet which is accepted without any further documents, but it's not just some bracelet which says "DNR", it is a non-removable hospital-type bracelet of an official design which has the name of the physician on it, if I recall. What I am trying to discourage is people engraving "DNR" on whatever bracelet or necklace they have, or tattooing it on their chest, without consulting a doctor or getting a proper order or anything else. This will generally not be sufficient, although, again, I don't know for your country or state or town specifically.

EDIT: Let me just add that for most people, a living will is really what they want when they think of preventing lingering in the ICU. A living will can say, for example, that in case you become unable to function, and your condition will not improve according to your doctors, you do not wish to be placed on a respirator, or have feeding tubes inserted, or to be resuscitated. (Of course you should consult advisers to put this together.)

A living will is not the same as a DNR order; it is more general. I think for most people it doesn't hurt to have it. On the other hand, walking around with a DNR order on you, if you are a person without a known great risk for cardiac arrest, is kind of pointless, IMO. You may, after all, become incapacitated in ways that do not involve cardiac arrest (like traumatic head injury or stroke).

A lot of people reduce advance directives / living wills down to DNR or not DNR, but actually that's the least useful bit of an advance directive.

Advance directives should ideally cover all the situations in which you lose mental capacity. Who do you trust to make medical decisions on your behalf; who do you trust to take financial decisions on your behalf; do you care what happens to your corpse, and so on.

Counterpoint:

> " 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."

Of course, the success rate (where success is defined as the patient going on to live a reasonably normal life) of CPR performed in the field might well be much higher than CPR performed in the hospital.

I actually don't disagree with that, although the statistics will vary depending on the population served by this particular hospital (e.g. hospital near a ski slope which sees a high number of relatively healthy people who collapsed due to an accident or hidden medical issue will probably have better rates).

Unfortunately, the "median" resuscitation call, in my own experience, is for something like "77-year-old cancer patient who is unconscious". We get there and see that there is no pulse, we have to go through the motions if there is no DNR order, but everyone knows it's hopeless, since it's not like we can cure cancer while we do chest compressions. Sometimes we can get a pulse back, but we know - although not "officially" - that the patient will be pronounced dead at the hospital within a few hours. Now I will say one thing here - it is often easier for the family to go through this process, since they can feel that "they've done everything till the very end", although from the point of view of medical practice it would be better to have a DNR order; that's really the type of situation that these orders are for.

But to reiterate - if you don't actually have disease that you know of, I would personally recommend giving yourself a chance, like that guy with the pneumothorax got. it's up to you, of course.

Though I would say that a living will is probably more useful for most relatively healthy people than a DNR order, since you can end up in a situation in which you are unable to function without any resuscitation being involved. I think a lot of the people commenting in this thread are really thinking of these more long-term situations, rather than resuscitation, which is an on-the-spot decision.

Just to clarify he was saying that the guy with the pneumothorax walked out because he didn't need CPR in the first place

I think he was talking about field CPR "...brought to me in the emergency room after getting CPR..."

Saving life has priority over a few broken bones. If someone has a tension pneumotorax you can detect it easily when you do the CPR, you can see it and can hear it, a pneumo can even stain your gloves with pink, so this is probably a false problem.

> 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."

I thought they required surgical patients to be wheeled out, regardless.

Some hospitals require everyone admitted to be wheeled out, or minimally have a nurse with a wheelchair walking next to you - regardless of why you were in the hospital. But alternatively, most outpatient surgical facilities don't have this sort of thing. And furthermore, not every hospital has this sort of rule either.

I took a class on medical ethics and they had an interesting perspective: "you can be sued for any reason; what matters is whether you will be held guilty."

The risk of legal action shouldn't change one's conduct.

An interesting perspective, but false. Risk of legal action should definitely inform your conduct, unless you want to go broke. You can easily spend all your money paying lawyers to defend you right up until the point you are declared "not guilty" (or in a civil case, until you win). That doesn't make it a good idea.

So yes, you should always try to do the ethical thing. But your moral calculation should at least consider the risk of being sued and take that properly into account.

This is an excellent point. This calculation can change depending on a doctor's employer too. If the doctor is self-employed, the strategy is definitely don't get sued at all because the cost of defending could break the bank.

At a big hospital, the doctor might not have to pay for lawyers personally, but the hospital or the insurance company might have very clearly defined rules for when the lawyers get paid for, so the doctors may not have much choice about treatment.

I'm not aware of the costs involved. Is professional liability insurance prohibilitively expensive or not available to self-employed doctors?

>the doctors may not have much choice about treatment

What do you mean by this?

I think it's reasonable to assume insurance companies will defend a doctor whose conduct is based on solid evidence or law. Are their rules not aligned with current medical practice?

You can as a private doctor carry insurance (at least as far as I have been told). Insurance either way is extremely expensive, because it's so easy to lose a case. The problem is that the law is very complicated when it comes to malpractice. . . . .and it's big money. You may have done everything right and some attorney still finds fault and is able to convince a judge of your wrong doing. Everything gets called into question and rarely are actions black and white

"Did you do this?" "Yes." "Why didn't you do this instead?" "Based on the circumstances, it didn't sound reasonable" "So you're not experienced enough to consider that as an option? Should you be practicing medicine?" etc.

Once you get convicted, that sticks with you like a stigma, even if it's total B.S.

This forces doctors/hospitals/etc. to follow exact established procedures to try and reduce the possibility of getting sued. It's called defensive medicine. Their decisions are what are best for them, and not necessarily in your best interests, and let me say this: I don't blame them for it. Having grown up with doctors, lawyers, and lawyers who defend doctors in my family, I can tell you getting sued positively sucks . . . . except for the plaintiff's legal team, they pretty much win, if they are any good at it.

So the vast majority of doctors are condemned? That sounds like a very unfavorable environment for medical practitioners. I think its only natural to try and protect oneself.

From 2000 to 2004, in one of my country's states, 372 doctors were taken to court but only 23.9% were condemned¹. The number of lawsuits have been increasing ever since; I found a news article with more recent figures from another state but couldn't find the actual source of the numbers. It said 35% of verdicts were guilty.

¹ http://dx.doi.org/10.1590/S0100-55022007000300004

That's what insurance is for. The problem with dancing in ethical lines is that you're going to get careless and cross over too far.

>When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. > But doctors still don’t over-treat themselves.

This is an interesting article. The main point is that nobody, in general, is prepared to be in a almost-dead situation, and when this event comes, the patient nor family is prepared to answer "ok, I prefer more life quality than trying all possible treatments". Because the implicit answer is that when you give up all alternatives, you are saying "I prefer to live few months and die".

Not that choosing all treatments might be different. But it's a possibility, it's a try, and it's not "giving up".

Doctors, on the other hand, deal and see all the side effects of the treatment. They know what will cost (in quality, not only money). And if the end will come anyway...

As a doctor, when I am running through an Advanced Care Directive (ACD, what a DNR order is called in NSW Public hospitals) (I do it with all patients older than 70 that present to the emergency room), if they say they want 'everything', I say, yes, we will do everything that is in your best interests. But let's think about this case. If your condition was to deteriorate and your heart was to stop, would you like CPR? This would break all your ribs and also require a breathing machine. What about if you were to stop breathing and require a machine to breathe for you? Would you like to be attached to a ventilator? What about if you could not feed yourself? Would you want a feeding tube inserted?

Often by making people confront the actuality of what resuscitation means, you can change their ACD to something that is both medically appropriate for their condition and satisfactory for them, as they may have never thought about it in the terms you are describing it

This Radiolab story (2013) covers the same theme:

http://www.radiolab.org/story/262588-bitter-end/

It notes the discrepancy between doctors' preferences and the general public's and points to the role television medical dramas play in explaining it.

I've always been in the "If I'm too ill to enjoy life, please let me go" camp. Still, this was one of those pieces that significantly tilted how I look at an issue.

Many people think that when they see an ill person. I wouldn't want to live like that. In reality it sneaks up on you so slowly that by the time you are in that situation, you do want to live like that. My dad saw his dad slowly die of dementia and told me he wanted to get a cyanide pill and always have it on him. When he got in that condition and was restricted to bed in a nursing home and we asked if he wanted DNR, he was pretty clear that he did not. One could argue whether he understood.

The only patient I ever saw who was eager to die was an end stage lung patient with horrible air hunger. He said enthusiastically "doc, let's do this" (he meant give me enough morphine for the air hunger that I stop breathing). It was kind of chilling

I have been thinking about this too and I also concluded that it will be hard to find the cutoff point. Most diseases take years to develop. How do you decide you had enough?

If you go via dementia by the time you get there you long ago lost the ability to act

More like fear is not present when they make that decision for "future me", and is present when making that decision for "present me".

A living will (and a regular will too off course) is a blessing for your family as well. Make your end of life care decisions now so your loved ones don't have the burden of deciding them for you in case you are unable to make these decisions. And talk to your family as well so they know your wishes, even if you are young you never know what tomorrow will bring.

Yes!

We'll all die one day. We don't have to be pessimistic and gloomy about it but we do need to prepare. We all hope it won't be right away but yet there's no guarantee in life. Everyone has different priorities when things get rough, but without planning, the regular defaults apply, and they (usually) aren't what you or your family want.

I guess it's only natural. I don't expect non-technical people to make the same technical choices I do, nor can I recommend them to the general population.

I suspect that it's the same with doctors, but their field happens to be the workings of disease and their treatments.

Assuming this article is accurate, it shows what type of a clownish dystopia the USA has found itself in. We force the government (i.e. the collective US citizens) to pay for end of life treatment for people who didn't budget for it themselves, and which also appears to offer a worse utility than doing nothing according to the revealed preferences of the very people who are responsible for administering these treatments.

That is, we are bankrupting our nation to make people more miserable.

One of the best types of death one can wish for is one on a bed, with morphine, and slowly overdosing on it. I guess most doctors can arrange this kind of situation, should the need arise.

I can also imagine that doctors keep this in mind during their lives, but then because of practical concerns, they still die the normal way.

Also worth checking the "past" link, there are a few hundreds of comments already.

https://hn.algolia.com/?query=How%20Doctors%20Die&sort=byDat...

I imagine the letters to the left are important, but I guess I won't know for sure, because of social media.

The 2014 Reith Lecture, given by Atul Gawande, addresses these issues in great depth. Well worth a listen.

http://www.bbc.co.uk/programmes/b04bsgqn

It's a very tough issue. My parents both asked to not have extensive life maintenance due to issues they had with their parents. It's best to have the discussion with next of kin in advance.

The format of this page actually makes it very difficult to do anything but skim because the social media buttons on the lft cover up the ~ the first word of every line.

reads perfectly with NoScript ;)

Or go into the inspector and delete the offending node! I resort to that sometimes when the "loading" message obscures the (already loaded) content, but won't go away because no JS.

no script is the only realistic option on mobile though :(

Whaaaaaat is going on here? This article is from the Atlantic.

Edit: Saturday Evening Post

http://www.saturdayeveningpost.com/2013/03/06/in-the-magazin...

the irony is that most surgery advances that ends up saving a life 100% of the time with good quality of life, only get discovered because of thousands of people demanding the 5% with bad quality of life if it even succeds.

and surgeons love to practice the difficult cases because, as the article mentions, that's how they make a name for themselves.

Depression trigger warning

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We are not machines.

We are men.

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