Why should doctors die differently?

My attention was drawn to a recent headline in a local newspaper: "Doctors die differently than their patients." The article discussed the fact that physicians often do not request complicated treatment and life-sustaining therapies. It referenced a February 2012 piece in the Wall Street Journal by Dr. Ken Murray. Dr. Murray discussed some of the available evidence supporting the different decisions physicians reach regarding end-of-life care.

He quoted a 2003 article by Joseph Gallo and associates, who surveyed participants in the Johns Hopkins Precursors Study, which covered physicians graduating from Hopkins between 1948 and 1964. The investigators obtained responses from nearly 800 physicians regarding their end-of-life decisions. Compared with 20% of the general public, 64% of physician respondents had created an advanced directive. Additionally, nearly 90% of the physicians did not want CPR if they were in a chronic coma. This contrasts with about 25% of the general public not desiring "heroic measures." Clearly, physicians were taking the initiative and outlining the care that they did and did not want to receive in the setting of advanced medical illness.

Murray also mentioned a 1996 study that examined how CPR was portrayed in television shows and the potential impact it may have on patients’ decision making. In that paper, CPR was successful in 75% of the TV cases, with 67% of patients ultimately being discharged from the hospital (N. Engl. J. Med. 1996;334:1578-82).

Compare this with what we know to be true. CPR rarely works. A 2010 study that evaluated the impact of 95,000 cases of CPR in Japan demonstrated that clearly. Only 8% of patients who had received CPR survived for more than 1 month. Of those who survived, only 3% were able to lead "normal" lives.

Based upon our experiences, we are able to make objective assessments of the likelihood of success of various therapies in our patients. As hospitalists, we are often placed in the position of helping explain therapies provided by other specialists – cardiologists, oncologists, surgeons. I know that there have been times when I have seen patients receiving treatments I considered futile. I believe many of us have been in similar situations. Patients do not fully understand the risks and benefits of their therapy. Once the big picture is made clear to them, they often opt for more conservative therapy aimed at improving quality of life.

I believe we have an obligation to our patients to share with them the reality of the care they receive. We need to check in with our patients and understand what is important to them. Do they want to exhaust every medical option available? Are they looking to live long enough to attend a graduation or wedding? Do they value comfort and quality time above all else? We need to ask these questions and fully understand our patients and their desires.

I wrote previously about my former colleague Darlene. Had I not known her desires regarding continued therapy, she would have received care she did not want. I am certain of this because she was in the process of being transferred to the intensive care unit when I intervened at the behest of a mutual friend. She would have received several days of great, high-tech care in the ICU – and ultimately died despite that care, care that she did not want in the first place.

We, as hospitalists, must talk with our patients about their wishes. We must educate them about the likelihood of success of their therapies and of CPR. We must act as their advocates with subspecialists who too often focus on their specific portion of the patient, losing sight of the bigger picture. We need to do better. We need to ask the question: Should doctors die differently?

If advanced directives and dying in comfort are good enough for us, they should be good enough for our patients.

Dr. Pistoria is chief of hospital medicine at Coordinated Health in Bethlehem, Pa. He believes that the best care is always personal. 

My attention was drawn to a recent headline in a local newspaper: "Doctors die differently than their patients." The article discussed the fact that physicians often do not request complicated treatment and life-sustaining therapies. It referenced a February 2012 piece in the Wall Street Journal by Dr. Ken Murray. Dr. Murray discussed some of the available evidence supporting the different decisions physicians reach regarding end-of-life care.

He quoted a 2003 article by Joseph Gallo and associates, who surveyed participants in the Johns Hopkins Precursors Study, which covered physicians graduating from Hopkins between 1948 and 1964. The investigators obtained responses from nearly 800 physicians regarding their end-of-life decisions. Compared with 20% of the general public, 64% of physician respondents had created an advanced directive. Additionally, nearly 90% of the physicians did not want CPR if they were in a chronic coma. This contrasts with about 25% of the general public not desiring "heroic measures." Clearly, physicians were taking the initiative and outlining the care that they did and did not want to receive in the setting of advanced medical illness.

Murray also mentioned a 1996 study that examined how CPR was portrayed in television shows and the potential impact it may have on patients’ decision making. In that paper, CPR was successful in 75% of the TV cases, with 67% of patients ultimately being discharged from the hospital (N. Engl. J. Med. 1996;334:1578-82).

Compare this with what we know to be true. CPR rarely works. A 2010 study that evaluated the impact of 95,000 cases of CPR in Japan demonstrated that clearly. Only 8% of patients who had received CPR survived for more than 1 month. Of those who survived, only 3% were able to lead "normal" lives.

Based upon our experiences, we are able to make objective assessments of the likelihood of success of various therapies in our patients. As hospitalists, we are often placed in the position of helping explain therapies provided by other specialists – cardiologists, oncologists, surgeons. I know that there have been times when I have seen patients receiving treatments I considered futile. I believe many of us have been in similar situations. Patients do not fully understand the risks and benefits of their therapy. Once the big picture is made clear to them, they often opt for more conservative therapy aimed at improving quality of life.

I believe we have an obligation to our patients to share with them the reality of the care they receive. We need to check in with our patients and understand what is important to them. Do they want to exhaust every medical option available? Are they looking to live long enough to attend a graduation or wedding? Do they value comfort and quality time above all else? We need to ask these questions and fully understand our patients and their desires.

I wrote previously about my former colleague Darlene. Had I not known her desires regarding continued therapy, she would have received care she did not want. I am certain of this because she was in the process of being transferred to the intensive care unit when I intervened at the behest of a mutual friend. She would have received several days of great, high-tech care in the ICU – and ultimately died despite that care, care that she did not want in the first place.

We, as hospitalists, must talk with our patients about their wishes. We must educate them about the likelihood of success of their therapies and of CPR. We must act as their advocates with subspecialists who too often focus on their specific portion of the patient, losing sight of the bigger picture. We need to do better. We need to ask the question: Should doctors die differently?

If advanced directives and dying in comfort are good enough for us, they should be good enough for our patients.

Dr. Pistoria is chief of hospital medicine at Coordinated Health in Bethlehem, Pa. He believes that the best care is always personal. 

My attention was drawn to a recent headline in a local newspaper: "Doctors die differently than their patients." The article discussed the fact that physicians often do not request complicated treatment and life-sustaining therapies. It referenced a February 2012 piece in the Wall Street Journal by Dr. Ken Murray. Dr. Murray discussed some of the available evidence supporting the different decisions physicians reach regarding end-of-life care.

He quoted a 2003 article by Joseph Gallo and associates, who surveyed participants in the Johns Hopkins Precursors Study, which covered physicians graduating from Hopkins between 1948 and 1964. The investigators obtained responses from nearly 800 physicians regarding their end-of-life decisions. Compared with 20% of the general public, 64% of physician respondents had created an advanced directive. Additionally, nearly 90% of the physicians did not want CPR if they were in a chronic coma. This contrasts with about 25% of the general public not desiring "heroic measures." Clearly, physicians were taking the initiative and outlining the care that they did and did not want to receive in the setting of advanced medical illness.

Murray also mentioned a 1996 study that examined how CPR was portrayed in television shows and the potential impact it may have on patients’ decision making. In that paper, CPR was successful in 75% of the TV cases, with 67% of patients ultimately being discharged from the hospital (N. Engl. J. Med. 1996;334:1578-82).

Compare this with what we know to be true. CPR rarely works. A 2010 study that evaluated the impact of 95,000 cases of CPR in Japan demonstrated that clearly. Only 8% of patients who had received CPR survived for more than 1 month. Of those who survived, only 3% were able to lead "normal" lives.

Based upon our experiences, we are able to make objective assessments of the likelihood of success of various therapies in our patients. As hospitalists, we are often placed in the position of helping explain therapies provided by other specialists – cardiologists, oncologists, surgeons. I know that there have been times when I have seen patients receiving treatments I considered futile. I believe many of us have been in similar situations. Patients do not fully understand the risks and benefits of their therapy. Once the big picture is made clear to them, they often opt for more conservative therapy aimed at improving quality of life.

I believe we have an obligation to our patients to share with them the reality of the care they receive. We need to check in with our patients and understand what is important to them. Do they want to exhaust every medical option available? Are they looking to live long enough to attend a graduation or wedding? Do they value comfort and quality time above all else? We need to ask these questions and fully understand our patients and their desires.

I wrote previously about my former colleague Darlene. Had I not known her desires regarding continued therapy, she would have received care she did not want. I am certain of this because she was in the process of being transferred to the intensive care unit when I intervened at the behest of a mutual friend. She would have received several days of great, high-tech care in the ICU – and ultimately died despite that care, care that she did not want in the first place.

We, as hospitalists, must talk with our patients about their wishes. We must educate them about the likelihood of success of their therapies and of CPR. We must act as their advocates with subspecialists who too often focus on their specific portion of the patient, losing sight of the bigger picture. We need to do better. We need to ask the question: Should doctors die differently?

If advanced directives and dying in comfort are good enough for us, they should be good enough for our patients.

Dr. Pistoria is chief of hospital medicine at Coordinated Health in Bethlehem, Pa. He believes that the best care is always personal.