The following is a reprint from an article a friend of mine recently posted on Facebook. For the sake of simplicity I have left a link to the original post “How Doctors Die” by Ken Murray. The subject may or may not be controversial to pet owners but I think it is something that must be broached, especially for Ash and myself as we take care of so many pets.
Case in point is Magic, my stray cat whom I saved from imminent death from a shelter over a decade ago when I saw an ad to save her – even though I already knew that she was an older cat and not a “cute as a button kitten” that so many people go for. In the past few years, the doctors had been treating Magic who came down with hyperthyroidism. The suggested treatment for Magic was a one time radiation (radio iodine) treatment or oral medications for the rest of Magic’s life. Not being able to afford the $2,000 for radiation treatment we opted to go for the Methimazole (tapazole) pill which was a lifelong treatment in which a pet owner has to administer a tiny pill to their cat twice a day everyday forever.
We did so for almost two years, but I really question if it was the right choice or not. At that point Magic had already lived well beyond the life that she was supposed to and she lived in a grand fashion. Meaning the first half of Magic’s life from when she entered mine, I happened to be single and she was my only pet. That said I spoiled her rotten, she ate what I ate and the whole nine yards. And when Ash came into my life none of that changed.
Fast forward ten years and being diagnosed with hyperthyroidism and constantly being treated with medication: her personality changed and she preferred to be alone in some dark corner most of the time, Magic’s heart was still beating at a rapid rate, she was still skinny and overate, she was both lethargic and hyperactive at the same time seemingly, she farted more often, had constant diahrrea and peed excessively. Yet we kept her treatment up to keep her a live longer because she was a beloved pet and the doctors SAID that she could live many more years. However in contrast I think her last few years sucked and she didn’t live very well. She seemed uncomfortable and upset all the time.
This is where I think its most cruel and potentially inhumane to treat a gravely ill animal is it worth it all to extend their life a few years? I never anticipated owning so many pets after we bought our house, but I also didn’t realize how quickly time flies and that inevitably our animals will get old like us and die as well. For animals like ferrets and cats who have fairly short lives sometimes their natural life can come to an end rather quickly much like one’s teens or twenties or thirties even.
We as caretakers of our animals really need to think hard and long about what our actions will be when its time or near time for our pet to pass. Will we have the courage to think about the animal and not ourselves?
Are we really keeping this animal alive via treatment to improve and extend the animal’s life or are we doing so because we aren’t prepared for the consequence of not having this pet anymore in our life.
IN REALITY DOES THEIR LIFE WITH TREATMENT STILL SUCK? as compared to when they weren’t sick at all? In the latter case are we making our pet needlessly suffer because we can’t let go or think we are doing the right thing?
Its something that I have asked myself often the past two years as I watched Magic waste away. One of our ferrets died this year as well as our Mean Snake. Our other ferret is inevitably going to pass in the next years and I question whether or not he is living a good life right now. His adrenal diseases which you can thank Marshall’s for seems like a crappy disease to have even with treatment.
In either case of our first ferret and the Mean Snake the decision to put them down were clear-cut. Ren, our ferret was already very old as far as ferrets go and even with proper shots and daily oral meds she went quickly. She became paralyzed from the waist down and could not walk. Our King Rat (Mean Snake) lost its battle to septicemia and the disease had opened up her skin right to the stomach cavity. The last month of treatments and injections were all for nought, we felt better that we fought so hard to save his life but I don’t know if we should have now that we have 20/20 hindsight.
With these losses this year in 2011, it has forced me to ask myself if the time comes again for another one of our beloved pets to pass what will we do and which of us (Ash and/or myself), if at all, will champion for the animal that is sick or dying. I ask myself if we will do the right thing and just let the animal pass. For
Ash and myself sometimes I ask if we are cowards? The reason being is that we have provided clear instructions to one another for if we somehow ended up in a vegetative state or some other fatal or unfathomable condition we have instructed one another to not seek further medical attention to keep us alive. Very similar to what the doctors in this article wanted for themselves. But I ask myself, why we didn’t or couldn’t grant that same amount of humanity and grace to our animals and forced them to fight for their lives. Maybe it’s because we didn’t and can’t know for certain what they desire and I’m afraid I’m not able to read their minds and make a decision without inputting my own feelings into the equation. I know that looking back in all three cases it would have been better for the animals if we had put them down immediately yet we didn’t. If I had done that to Ash if she were gravely ill, it would have been against her instructions to me and unconscionable so why is it ok for us to seek treatments for our animals that only prolong the inevitable to extend their lives for an arguably short period time? I don’t have an answer for this yet, but I hope that at least you will think about this subject as well. Euthanasia whether in humans or animals can be a hard subject to talk about but I feel that we need to.
With our animals, we are very much their caretakers, they did not choose a life in captivity and cannot tell us what they desire. If we say oh look he looks like he has a will to live, I can’t say for certain if we are humanizing and expressing a part of our own feelings and injecting that into the equation for seeking treatment for a gravely ill animal. Each of us must make the hard decisionwhen the time comes to see one of our pets go and it must be dealt with in a mature and humane manner.
How Doctors Die
It’s Not Like the Rest of Us, But It Should Be
Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. 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 CPR (that’s what happens if CPR is done right).
Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. 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.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.
The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. 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. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.
But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. 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.
It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.
Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.
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. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.
But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.
Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.
We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.