How Doctors Die

[Shroom Man 777]

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.

*Photo courtesy of patrick.ward04.

I don't disagree with facing death this way. Calmly, coolly, entirely without incident.

[VarrusTheEthical]

I have to say, I've always understood that our medical system has been obsessed with preserving life without caring if said life is worth living. But I have never really thought about how that affects the doctors and nurses who are often forced to inflict unspeakable suffering on their patients in often futile attempts to save them.

[Shroom Man 777]

A system designed to profit, combined with lots of under-informed people who are afraid of death, isn't a nice combination.

I think a lot of this would be changed for the better if people were simply more educated in important medical/health care-related things. This isn't like physics or liberal arts or biochemistry that are optional in your lives. Everyone will pretty much get sick, get pregnant, have children, get into accidents, and die. And some of the things I've learned in nuersing school I think would be extremely useful for, well, just about any person (heck, why isn't the stuff they teach us in pediatric nuersing taught to all parents?) of any walk of life.

Better understanding and knowledge and stuff will help people come to terms with stuff like dying better and avoid choices that will just prolong pain.

EDIT:

Man, SCRawl, it was an intended misspelling! Doctorb! The 'b' stands for cheap!

[mr friendly guy]

They say some people are better at it than others at conveying to the relatives when treatment is futile. Apparently the trick is tell them about life support machines, and put the onus on them making the decision to turn the life support on when it doesn't work. They then turn the decision over to the doctors.

Certainly my experience has been similar to the author's. Sometimes its just not worth trying "heroic" measures. Most Australians seem to be fairly reasonable, before you even get half way into your speech they are already, no resus. Some of course burst into tears even though I stress asking about resus status is a standard question for people who are elderly with lots of comorbidities.

That being said one family was insistent I try everything on a patient who was frankly looked like he was going to die. Sepsis secondary to infected ulcers (which are only going to get reinfected again because he has poor circulation). You can see all the oedema from the fluid we gave him to bring his blood pressure up, but the family insisted, and got agitated when the ICU refused to admit him. They even demanded I give the name of the ICU doctor, which I refused because I was afraid they will harass her. I remember one part of the conversation went like this

Relatives : We want him to get everything. I mean if this was your mother, what will you do?

Me : Actually my mother has already indicated to me that she wants us to let her go quietly?

Relatives (long pause) : Well we are different.

And yes I did manage to save him using antibiotics, concentrated albumin to provide the oncotic pressure to suck out the fluid causing peripheral oedema back into the circulation, and then diuretics (which seems paradoxical given that we gave fluid to bring the blood pressure up, but trust me, this works because we suck up more fluid into the circulation). Shortly after discharge he came back with the same illness, and he will continually get infection through ulcers. This isn't really much of a life, but its theirs and they can choose how to live it. I most probably wouldn't want that.

[SCRawl]

As Shroom can attest to, it isn't just doctors who are so aware of the negative outcomes from too much "end of life" care; nurses share a similar awareness. My mother (who was a nurse) got the news that her cancer would kill her in about three weeks -- and it did, ten years ago this week -- and all she wanted was to die at home. She couldn't, in the end, but at least she didn't have to spend a few "extra" weeks in even greater discomfort. She knew enough that there wasn't any hope, and that her circumstance could only get worse by intervening more.

[Serafina]

Two points would interest me:

- is this specific to the us-American health-care system?
I actually doubt that, it seems like a general human issue to me.

- can we give this awareness of when medical care will be ultimately futile to people without medical training?
This would be important in lowering overall healthcare-cost - if people willingly refuse useless care, it would free up funds for healthcare that can actually save/improve lives. Sadly i have no idea if or how this could be done.

[Broomstick]

Huge issue for my sister, who is a hospice director as well as an MD. Her job is all about relieving suffering and improving quality of life, not prolonging it.

There are circumstances, such as after major injuries/burns, where a patient may be subjected to horrifically painful procedures but the difference there is that there is hope that, after the medical stuff is done, of a meaningful life worth living. Heroic measures aren't always futile, the problem (to me) seems to be inappropriate use of them. Someone who is healthy but suffering trauma? Yes, it can be worth it. Elderly, ill, and dying? Let them go.

This came up with my mother. Both she and the family were ready to call it quits before some of the doctors (all of them young, I noted at the time) who had obviously been trained to save lives, save lives, save lives but hadn't (yet) become experienced enough to know when to quit. Mom was in a 77 year old body that had been ravaged for a lifetime with severe cardiovascular disease, and she no longer had adequate circulation anywhere to heal anything. She asked to go home. Of course, with mom suffering from some dementia as that point it was all too easy to dismiss her words and say she didn't have the capacity to understand the consequences. Well, yeah, mom had dementia but she wasn't that far gone, she did know that it would mean her death. But she didn't want to die in the hospital, tied to a bed (when mom got delirious all her mind focused on was leaving, so she'd try to and wind up on the floor - once she was home she stopped trying to get out of bed and there was no need of restraints). So, dad, with a long-established power of attorney, said we'd take her home (with full support of us kids). This pissant little doctor, probably just out of med school, more or less accused us of killing mom. Said we wouldn't be able to handle it (Dr. Sister set him straight on that one, what with running a hospice herself and dealing with the dying as her job). So we went over his head, and his superior didn't have a problem with us doing that, and setting up hospice. Mom died peacefully at home, in a quiet room, with just her loved ones around and not a hospital roommate or nurses/doctors/whatever trooping in and out constantly. No last-ditch attempt to resuscitate her. This might be morbid to say, but hers was one of the most peaceful looking corpses I've seen, probably because she hadn't had the crap beat out of her trying to keep her alive. She really did look like she was deeply asleep, and that's a rare thing in the deceased before they're prettied up by the funeral home industry.

The system is so slanted towards intervention that getting it to stop might require effort - it would have been all too easy to yield and leave mom in the hospital, but I'm glad we didn't. I can see where other people, stressed, uninformed, in fear, might yield to the aggressive young doctor.

I'll also add that, while in-patient hospice does have some very hospital-like aspects to it, it's not a hospital. It's essential for families who can't handle in-home care (that really does take considerable effort, and not everyone is emotionally equipped for it) and patients whose conditions can't be readily managed at home. Resuscitations aren't done at an in-patient hospice. My sister spends a certain amount of her time each day having to educate students rotating through the place about the difference. I was visiting her one day when she got a call from an agitated young doc in training who was nearly hysterical because something about a patient's kidney and liver functions was going south and no one in the place seemed concerned or willing to do anything. My sister had to repeat, over and over, that the patient was in hospice because he was dying. He and the family had been informed, presented with options, and opted for doing nothing and that choice MUST be respected. It was completely counter to the young doc's prior highly interventionist training. It can be very hard to do nothing and watch a patient die.

Hell, when my mother breathed her last I had an impulse to leap up and do CPR myself, because you're so conditioned to do something when someone stops breathing, I had to force myself to not act. It can be very hard to let go, even when you think you're prepared, even when intellectually you know it's the right course to take. Death hurts. The dead don't feel the pain but those still living do, and I can understand the impulse to try to avoid that particular pain, even if long-term it's not a good choice for anyone.

[Broomstick]

Two points would interest me:

- is this specific to the us-American health-care system?
I actually doubt that, it seems like a general human issue to me.

No, it's not. However, there aspects to the American system that encourage too much intervention for some people (there are other instances where not enough is done, but that's a different topic.

There are also social aspects to this. For example, members of a historically oppressed minority, where there were past instances of their sort either not having full access to care, or even being left to die by the larger society, might be more inclined to insist on "do everything" out of fear that their loved one is dying not because they really can't be saved, but because the "establishment" doesn't value their lives. Other countries may or may not have that factor at work, or at work to greater or lesser degrees.

Religion can also tie into this, either making it easier to let go or harder depending on how the creed views death.

Then there is life experience - my sister has had a few Holocaust survivors in her hospice. Dealing with the issues of someone who survived attempted genocide (along with any issues it may have generated in the larger family) isn't fun. You're talking about someone who experienced nearly being exterminated by a government and society, being killed by people in white coats and/or left to die is not an irrational fear in these folks. (Then there's the issue of how do you deal with someone who is not in physical pain but, due to their condition, is vividly relieving life at the death camps and/or escape from same - how do you deal with a frail, dying person who really is re-living hell?) You're kind of screwed on that one - intervention can re-ignite fears of medical experimentation and torture, not intervening can be seen as abandonment.

On top of all that, there is an impulse to avoid death. Of course, it's not 100% (otherwise we wouldn't have heroic self-sacrifice, or suicide) but it is there. Normal people generally don't want to die, they want to live. Even non-normal people, like the handicapped or chronically ill, usually want to live. Stopping intervention, stepping back, and letting death happen isn't the first impulse for most people. It's something they have to consciously choose to do, and in some instances, exert effort to do. Often, allowing intervention is the (short-term) easiest course. 150 years ago, where there wasn't a lot that could be done anyway, doctors ran out of things to do much sooner, and I think there was less expectation of heroic last-minute rescue. Now there is so much that can be done, the hard part is knowing when to stop.

- can we give this awareness of when medical care will be ultimately futile to people without medical training?
This would be important in lowering overall healthcare-cost - if people willingly refuse useless care, it would free up funds for healthcare that can actually save/improve lives. Sadly i have no idea if or how this could be done.

Yes, I do believe we can do this. At present, our society isn't set up to do it, but I do believe is can be done. The mere fact that hospice exists, that people ask for it, seek it out, is an indication that this knowledge can be given to non-medical people.

During the 20th Century the medical profession went from being able to do comparatively little for the dying to being able to do too much. Society - both within medicine and at large - has not yet caught up with this. It is, though, it really is. In late 1960's when my maternal grandmother died (largely of the same problems that killed mom) no one could stop the doctors from trying to resuscitate her. No one. There was no mechanism in place to allow them to NOT try, the law essentially compelled heroic measures no matter how useless. There are now legal mechanisms in place to shield medical personnel who either respect explicit patient wishes, or who seek to end intervention on the basis of "it's doing more harm than good". More and more people are putting their wishes in writing. The idea that we should, at some point, stop intervening has gone from inconceivable to something everyone has at least heard of, even if they don't agree with it. It used to be that paramedics and other first responders where not permitted to heed "do not resuscitate" orders, now there are legal mechanisms in place so that if a paramedic answers a 911 call and is presented with a DNR document he need not go through useless motions out of fear of prosecution. (For years, my mother feared being in a car accident and winding up resuscitated against her wishes. It was a relief to her when the law was changed in her area.)

[Shroom Man 777]

When the person passes, either gently or after a hard fight involving lots of procedures, the family and loved ones will still face that eventuality. I think letting them understand, accept, and come to terms with it will not only make it easier for them to go with a do not resuscitate and ease the person's suffering, but will also help them with the emotional issues that will come after the person passes.

[The Duchess of Zeon]

When my father died, he spent his last three days in the hospice care of a Roman catholic hospital facility. They didn't try to operate to relieve the pressure around his heart. I had mixed feelings about this, because he was a fighting old bastard of a man, tough, who'd seen every upset and event of the 20th century and participated in more than a few, and it seemed he'd rather go down fighting in pain than peacefully. But when he started taking off the oxygen mask in frustration at all the things on his body--he was more interested in watching a college basketball game than continuing to receive treatment--I accepted it, and so did the rest of the family. He was moved to hospice care, and there, late in the night, he slowly slipped into delirium as his body ceased to get enough oxygen as his heart was strangled by the fluid around it. But before that, when he was perfectly lucid, we had a wonderful conversation about whether or not there was an afterlife "Perhaps there won't be one with Margaret? Perhaps there's no afterlife? Or many lives?" he said; and then after that we listened to the complete length of Shostakovich's 8th Symphony off my laptop, looking out on the Everett symphony hall where he had first taken me to see orchestral performances. And then he slipped away, even though it took another 36 hours for his body to officially die. There were no machines, and though the room admittedly looked like it was in a hotel decorated in the 1970s, I at least have a last memory of holding my father's hand and looking out with him over the city lights while the haunting strains of that most tragic of symphonies drifted to its conclusion. I still can't write this without crying, but they are not really tears of upsetness.

[loomer]

My maternal grandmother suffered a great deal due to emphysema and lung cancer when I was very little, and it made her death something of a blessing. The only reason she suffered as much as she did was because of the lack of legal euthanasia (my grandmother campaigned to be the first woman to die that way in New South Wales), which is really tied into this entire issue: People who are going to inevitably die a painful death should have the right to choose a quicker, easier ending, and with all the drugs and techniques being used to prolong life these days, that right is going to be needed more than ever with the increasing aging population.

[Forgothrax]

I think a lot of this would be changed for the better if people were simply more educated in important medical/health care-related things. This isn't like physics or liberal arts or biochemistry that are optional in your lives. Everyone will pretty much get sick, get pregnant, have children, get into accidents, and die. And some of the things I've learned in nuersing school I think would be extremely useful for, well, just about any person (heck, why isn't the stuff they teach us in pediatric nuersing taught to all parents?) of any walk of life.

Truth. So much. Or the stuff in obstetrics... I just finished my peds & OB nursing rotations and there's so much we learned that the public doesn't, or they don't get it in a form they understand.

As for me... I totally get that. I've told my family before, if I end up in a situation where I'm brain-damaged, pull the plug. I do not want a life in which the only thing left of me is my shell. Same thing with Alzheimer's/Dementia... I work in that setting, and if I got diagnosed I'd go home, lay out my affairs properly, live my life until I noticed it starting to affect me and then go shoot myself in the head. Some things are not worth living through.

[Dave]

some of the things I've learned in nuersing school I think would be extremely useful for, well, just about any person (heck, why isn't the stuff they teach us in pediatric nuersing taught to all parents?) of any walk of life.

Could you share, Shroom? Granted this would require more lucid prose than you normally write, but I think we would all appreciate having read the results. Maybe a new topic in OffTopic, or a series of blog posts, or something?

[Broomstick]

I wouldn't mind Forgothorax contributing to that as well.

[The Duchess of Zeon]

I agree wholeheartedly, Forgothrax. I'd feel like I had a choice between putting my family through years of brutal agony as a thoughtless husk with no relevance to who I was, just a mockery, versus a single event of agony, and the choice between the two would be quite clear.

[LadyTevar]

I don't see them in the hospital, but I do deal with death all the time. I've got my Power of Attorney, my Living Will, and even my cremation set up and paid for. Nitram has his as well, and we both have asked for No Resus.

Which makes it even more ironic that we're waiting on a new liver. Nitram is still young enough to want to LIVE, not just survive daily. He hates being stuck inside, weak and easily exhausted. He wants Quality in his life. I want him to have that quality as well.

[mr friendly guy]

Two points would interest me:

- is this specific to the us-American health-care system?
I actually doubt that, it seems like a general human issue to me.

I suspect its mainly a human issue as we get this in Australian commie socialised medicine as well. However that being said, in the public system we aren't financially encouraged to do useless procedures, because we get paid just as much. Not that I think its common for doctors even in private to just insist on every procedure for a little bit of money, as its quite common practice for private doctors to admit their patient in the public system if their insurance doesn't cover the required treatment. Once admitted as a public patient its covered by the government.

- can we give this awareness of when medical care will be ultimately futile to people without medical training?
This would be important in lowering overall healthcare-cost - if people willingly refuse useless care, it would free up funds for healthcare that can actually save/improve lives. Sadly i have no idea if or how this could be done.

I do this all the time. Doesn't always work of course.

[Shroom Man 777]

some of the things I've learned in nuersing school I think would be extremely useful for, well, just about any person (heck, why isn't the stuff they teach us in pediatric nuersing taught to all parents?) of any walk of life.

Could you share, Shroom? Granted this would require more lucid prose than you normally write, but I think we would all appreciate having read the results. Maybe a new topic in OffTopic, or a series of blog posts, or something?

Like the childhood developmental stages and pediatric child care and like how to raise your child up so he can achieve all sorts of developmental milestones as a little kid and won't grow up to be a messed up dreg is, like, was one of those things that made me go "woah everyone needs to know this". You see parents who always tell their kids to don't do this or don't do that, when it's part of their natural and normal development to go out be little rascals. Or parents who have no idea that it's normal for two year old toddlers to be horrible and keep on going "no!" to anything you ask, and because the parents don't know that these things are normal for kids and that there are ways to address this (instead of asking the kid a yes or no question wherein he'll just go "no!", you can ask a two-choice question so he'll have to choose a choice, like "do you want to have a.) dinner first or b.)starve take a bath before dinner"), they end up getting all angry and whatever blah.

Some of these things are common knowledge, I guess. Or not. But it was nifty to have some of these common sense things explained so people can understand them.

Heck, for non-pediatric stuff, you can have "if your patient has pneumonia, when he lies down, incline the upper part of the bed upwards by a few degrees so all the horrible fluids in his airway will be pulled down lower by gravity so he can breathe". Or, if you're doing first aid to an unconscious person and he's on a lying position, put his head sideways, so whatever fluids accumulating in his airway can leak out sidewards rather than stay in his airway and drown him. You think this is obvious, but those guys who got knocked out by anesthetic gas and rescued in the Russian theater siege died after the Russkies killed the last terrorizers because the guys who rescued them forgot to do this, so I guess it's not too obvious.

Anyway these are really basic derp examples.

There's a whole lot of really "man everyone should know this stuff" things you can learn in healthcare-related fields which is why I never regretted taking up nuersing even though over here the nuersing-bubble bursted and the market is oversaturated with a surplus of nuerses, more nuerses than the hostipals here need IIRC (because the whole nuersing bubble here is predicated on the axiom of "the country sucks, get a job that's in demand abroad and GTFO and earn dineros").

But I'm digressing.

[Forgothrax]

To follow up Shroom...

I won't get into a lot of detail, if there was sufficient interest I'd have to start a new thread.

-Signs/symptoms of some of the most common serious diseases (asthma, anaphylactic shock aka allergic reaction, cystic fibrosis, diabetes, heart problems, etc). Also, the difference between bacteria and viruses and the methods of treatment thereof. I am not an evil person because I am withholding the magic antibiotics that you know I'm just hoarding in the back room, I'm withholding them because they WON'T TOUCH A FRICKING VIRUS (and because that's the doctor's call, not mine. I can't give you meds on my own authority.).

-As Shroom said, developmental stuff. So important.

-Basic first aid and life support. Parents should be able to use very basic medical equipment to stop a moderate bleed on extremity or torso, clean wounds properly, deal with burns and insect stings, keep an airway unobstructed, provide a basic report to a medical professional over the phone, hydrate a child and monitor their hydration level, and do CPR. Basic infection precautions for treating children (masks, gloves, or at least basic handwashing) are also in order.

-Immunizations. Explain how they work and the diseases they protect against. Show some pictures of, say, haemophilus influenzae and polio, explain the incidence rate, and contrast that to the autism rate. Explain that the claim that vaccines cause autism is a blatant lie created by a doctor who falsified study data in exchange for payment from a group of lawyers who wished to sue the British government. Explain that we have a system in place (VAERS, Vaccine adverse Event Reporting System) that exists solely to prevent vaccines from doing harm and that the system has worked in the past.

[Shroom Man 777]

Sometimes, one of the things that make "peaceful deaths" impossible is that even though you yourself are totally cool with dying without being hooked up to machines, after you lose yourself, your families might still have trouble letting go. Like Broomy said, there is the whole "must help, must make person live no matter the cost" thing going on in people's mindsets. But there are those kind of people who just don't want to talk about death. If you go "I want to die this way and cremate me" they'll go rapping on wood and go "heaven forbid" and avoid any conversations like that, and man, if you have families and loved ones like that... yeah.

Communication and talking about it would help, but some people are just, ugh. You'd think their unwillingness to see someone pass on would mean they really really love the person, but it doesn't have to be that way either. I can totally imagine people who act like total dickweeds to a guy, and then when the person goes into a coma and shit, they'll all act oh so concerned and ask everything be done to save the person, hook him to so many machines that the hospital room starts looking like a factory, maybe it's because of their own guilt at how they've treated the guy and now they're trying to make up for this and they want to do "good"? Or maybe just not letting go of life is something that taught to em?

But yeah, I imagine there are people like this, and some of you guys might've seen or know people like this too.

I think having pleasant experiences before the time comes can help families and such come to closure and be more comfortable with the eventuality of a loved one passing on. There's the whole satisfaction thing, no more hangups, there's nothing left unsaid, and while it's always sad to see someone go, those left behind won't spend the rest of their lives beating themselves up over this or that, and all sorts of regrets and whatever.


Hmmm... what's even more messed up is when terminal illness happens to children. Because not only do we have all the issues already mentioned by everyone. But there's also the whole "s/he's too young" thing going on, and because it's just so damn unfair for a person to pass on at such an early stage in life when they're supposed to have everything ahead of them. And, gah, you really can't blame parents or loved ones or family for fighting tooth and nail in hope that the person will get better.

[Kanastrous]

When my father was in hospital (ICU) and on a distinctly downward path, the attending kept trying to corner my Mom (herself a physician, who took to calling him "Doctor Death" behind his back) into signing a DNR - he gave us a very detailed and necessarily gruesome description of what he would be obliged to do to Dad, should Dad arrest without the DNR being signed. Now, Mom's assessment was that Dad was going to rebound, and was unwilling to sign more I think out of an emotional it's not time to give up on him, and I won't make a gesture that says it is sense, than anything else, and in fact Dad did recover sufficiently well to move into a 'recovery center' (read: less-well-equipped-place-to-probably-die) where he stayed for some months before being brought home (where he in fact did die, within a few days of his return).

I think that their medical training (Dad was an MD too) probably helped in that at least the hospital wasn't an alien environment to them, and they pretty much knew how everything worked. All in all it did a great deal to undermine my confidence in current hospital and insurance practice in general, and in Johns Hopkins specifically.

[Knife]

Guilt is a horrible modifier in end of life issues. Guilt of the dying, guilt of the loved ones, the guilt of the loved ones for not doing enough, for not being able to care for them at home, not being able to pay for it, guilt at pain, real or imagined. As much as I hate social workers, we just don't have enough of the little bastards around to help with all this damned guilt.

As far as OB rotations? Hell, I think most of the country has that part down. Pregnant ladies are crazy, as are everyone around them. It's what happens when they take the little tike home that needs work. Shroom has it nailed down with developmental milestones. All those crazy ladies and men who pour resources into this and that so their kid hits one milestone early, only to have the kid be equal with peers a year later and a milestone later. The very concept that a kid isn't just a small adult is hard from some people to grasp.

[Shroom Man 777]

I also really wonder what it's like for folks who aren't accustomed to hospital environments to be in situations like these, or even in less severe situations like non-life threatening hospitalizations. To be in such an alien environment such as a hospital, to be bombarded with things that you never encounter in everyday life, even when the doctors try to explain things in a simple way I bet it's still quite hard. It must all be confusing and emotionally turbulent. Even more so for folks who aren't that well-educated, or who come from rurals or something (my relatives from the provinces have such strange notions, not only do they think hospitals are unclean places, but when we drive by cemeteries or hearses, they tend to avert their gaze or hold their breath or something, so for these odd superstitious or mortality-phobic people, hospitalization must be utterly horrific).

Even without studying nuersing, my mom's a doctor and she shows me around her workplace all the time and like I have no problems being prodded at with needles or seeing organs being biopsied. But for ordinary people, these things would be uncomfortable.

But who am I to say, really. I've never tried being hospitalized, ever.

[Kanastrous]

Mom and I actually spent a fair amount of time with our 'neighbors' - people whose relatives were in the same ICU block as Dad - and her professional experience let her offer some help and support from a trained and experienced physician's viewpoint, alloyed with that of a person with a loved one there as a patient, as well.

Still remember some of those people, and their families. One kid who had survived a car crash with an appalling laundry list of fractures, ruptures, lacerations and bleeding (who made it out of ICU). One much older fellow who had come in displaying symptoms of Guillain-Barré Syndrome (which Mom had to point out to the attending as something to consider; he didn't think of it and boy did he turn unpleasant when it turned out she'd called it right), who alas did -not- make it out.

[PainRack]

I have to say, I've always understood that our medical system has been obsessed with preserving life without caring if said life is worth living. But I have never really thought about how that affects the doctors and nurses who are often forced to inflict unspeakable suffering on their patients in often futile attempts to save them.

We mount the Deathwatch, or Death vigil, or any other crude means of expression you want to call it apart from the bloody stupid hospital term of comfort measures, DDIL or End of Life care.

As nurses, we then curse the doctor for mandating some screwed up blood test, CE x 3 for chest pain, IV hydration or the like even when the person is so swollen that when I inserted the IV cannula, what leaked out was serous fluid instead.

Oh goody, the patient was bleeding out actively and you want me to do a serial CE x 3 because he complained of chest pain? What are you going to do if he does have a heart attack you idiot? Come on. Listen to the nice missy in the corner, and both of us get less work and you just up the nice painkiller so that my poor patient doesn't have to moan in pain more than neccessary.

You also then get the guilt and funny feelings like when I escorted the patient who had climbed out of bed into a chair.I put him back onto the bed, attached the oxygen mask back on him, turned around to talk to the son about how I'm going to show him oral care and when I turned around, he was dead. Just 5 seconds from alert, agitated guy who's probably going through the end of life stages(extreme heat and sensation of being enclosed) to a cooling pale body.