The stimulus for this week’s column was taken from an article by Dr. Ken Murray, Clinical Assistant Professor of Family Medicine at USC. The thrust of the article was on looking at how much medical intervention should there be in the end of life scenario.
He began the article with: “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 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.” The thing to note here was that in tripling the “five year survival odds from 5 percent to 15 percent” it was achieved with a poor Quality of Life (my capital letters).
I also read an article the other day referring to advanced breast cancer survival rates and compared two similar kinds of cytotoxic drugs. The end result of the study was that Drug A was more effective than Drug B, but had significantly more side effects as well. Reading further, it was reported that Drug B extended life by 13 point something months, while Drug A had the sufferer living 15 point something months; however, the downside included mouth ulcers, infections and low blood counts. Nonetheless, the researchers had come to the conclusion that Drug A was best. I ask you, best for whom?
Some of you may have attended one of my lectures on that same subject that I call The Quality of Life. In fact, I used to have a motto on the wall of my surgery which went “An increase in the Length of Life is not equivalent to an increase in the Quality of Life.” This is the lead-up to the concept of the Living Will, where you say ‘how’ you would like to die. A strange concept for some people, but one that you should get your head around!
Going back to Ken Murray: “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.”
Now there are many reasons that terminal care can end up as a full-blown medical emergency, and cultural concerns is just one of them. Then there is the fact that doctors are trained to save lives, come what may! Noble this may be, but does not stand scrutiny in the terminal situation.