A physician’s introspective comments about why he and his fellow physicians often forego the same end-of-life treatments they offer to patients has spurred a national dialogue, led to renewed interest in the Johns Hopkins Precursors Study of physicians, and provoked discussions about advance directives (AD) (eg, a living will or durable power of attorney for health care) and “the good death.”
Last November, Kenneth Murray, MD,1 a retired Clinical Assistant Professor of Family Medicine at the University of Southern California, wrote an essay, “How Doctors Die: It’s Not Like the Rest of Us, But It Should Be,” as part of Zcalo’s “Remedies” series.
“They [physicians] 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,” Murray wrote. “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 . . . .”
He condemned futile care, “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.”
In exploring why physicians administer so much care they wouldn’t want for themselves, Murray explained that often the patient has made no advance plan for the situation, and consequently, “shocked and scared family members find themselves caught in a maze of choices.”
In addition, Murray said, the lay public has unrealistic expectations of what physicians and certain interventions, such as CPR, can accomplish. Physicians are reluctant to impose their views on the vulnerable, and if physicians advise against further treatment, some people may characterize them as “acting out of base motives, trying to save time, or money, or effort.”
Other factors mentioned by Murray include patients being “victims of a larger system that encourages excessive treatment” and physicians’ fears about litigation or getting into trouble. He cited a case in which he turned off a life support machine, per the patient’s prior expressed and written wishes and after speaking to the patient’s wife and hospital staff: a nurse reported his action to authorities as a possible homicide. (He wasn’t charged.)
In an adaptation of his essay, “Why Doctors Die Differently,” published in The Wall Street Journal, Murray2 added data from the medical literature about physicians’ use of the ADs for themselves, low survival rates with CPR, and attributes of a “graceful death.”
Both national and international media have covered aspects of Murray’s essays. In April, his original essay was selected for the collection The Best American Essays 2012.
Still, Murray, who had a private practice in general medicine for some 25 years, is surprised by the widespread response to his essays.
“I have been astonished by the huge number of comments (over a thousand) that are almost universal-ly supportive of what I’ve written,” he told Psychiatric Times. “I have been especially pleased to see the virtually unanimous confirmation of my observations by other health care professionals.”
Murray added that he felt humbled by the large number of very personal stories related by posters, including professionals, often describing terrible end-of-life experiences of family members.
“Virtually all are stories of overtreatment, and they often describe considerable guilt over the poster’s actions,” he said. “It tells me that we have a long way to go in providing care that people want for themselves.”
Murray reflected that physicians “have always had a bit of a self-imposed stigma of death equaling failure. Some physicians get caught up in that, much as do family, and push treatment beyond reasonable limits.”
But when physicians are the patients, the perspectives are quite different, he said, “because there is no one else’s medical expectations to meet other than their own, and their attending physicians tend to respect their decisions as being much better informed.”
Asked about his attitudes toward life-sustaining treatments, Murray responded, “In a terminal situation, most life-sustaining treatments prolong the death process, not the living process, but I strongly believe in patient choice.”
1. Murray K. How doctors die: it’s not like the rest of us, but it should be. Zócalo Public Square. http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus. Accessed April 25, 2012.
2. Murray K. Why doctors die differently. Wall Street Journal. February 25, 2012. http://online.wsj.com/article/SB10001424052970203918304577243321242833962.html. Accessed April 20, 2012.
3. Gallo JJ, Straton JB, Klag MJ, et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others? J Am Geriatr Soc. 2003;51:961-969.
4. Straton JB, Wang NY, Meoni LA, et al. Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study. J Am Geriatr Soc. 2004;52:577-582.
5. Wittink MN, Morales KH, Meoni LA, et al. Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study. Arch Intern Med. 2008;168:2125-2130.