While combing through my social media outlets recently, I came across an article that struck me. The article entitled “Why Doctors Die Differently” addresses a subject many professionals in the medical field know but don’t really talk about – that physicians die too.
The article explains how we, as physicians, understand the limits of medical therapy and procedures and often forego treatment when the end is near. It’s not that we are ready to die but that we understand the chances of surviving a cardiac arrest with complete neurologic function. We have seen the effects chemotherapy can have on patients and we sometimes think about quality more than quantity of life.
This article presented itself to me at the perfect time. I had a patient who was a 40-year-old female survivor of cervical cancer who was then diagnosed with aggressive cholangiocarcinoma. She was admitted to my service with symptoms of dyspnea and hypoxia caused by a pulmonary embolus that developed because she stopped taking her lovenox. On presentation, she was cachectic, weak, and in obvious respiratory distress. She had recently been told by her oncologist that there were no more treatment options because of the spread of the cancer. The patient never actually spoke during her hospitalization, partly due to her dyspnea and partly because her very supportive and vocal family would not accept that their loved one could not be treated and wanted to try every possible procedure, medication, and therapy.
I had multiple conversations with this patient’s family, but one conversation with her mother will stick with me for the rest of my life. I sat down with the patient and her mother alone after rounds (without residents and students) to provide details about the patients disease and prognosis. I explained that we had no more treatment options to offer and would like to make the transition towards palliative care. When I broached the topic of a DNR, the patient’s mother immediately refused. I tried to reiterate that we weren’t going to be able to treat her daughter and that the cancer would progress to the point where her daughter would not be able to sustain herself on her own. Her mother, who was obviously tired, frustrated, and sad looked me straight in the eye and said “What would you do if you were me?”
I couldn’t answer her question. I was taught never to make such decisions for patients and was told to keep my opinions to myself. I froze for a minute and politely said, “I can’t say what I would do as a family member but as a doctor, this is what I would do.” I know my response didn’t suffice and I felt I had let the patient and her mother down. I know that my perspective as a doctor is very different from that of a nonmedical family member. I also don’t have the life experience to literally put myself in the mother’s shoes.
I went home that night thinking about this conversation and tried putting myself in the patient’s shoes. If I had terminal cancer, I wouldn’t want my family members to have to make such decisions. If only there was a way for me to plan ahead in case something did happened …
“ding ding ding”
..the bells in my head went off, the light bulb turned on, and I decided that I had to fill out an advanced directive. I never thought I would fill one of these out at the age of 27, but I know now it’s the right decision. I also have asked my parents to fill out their advanced directives and assign a durable power of attorney for medical decisions.
I believe the reason so many more physicians than patients prepare these documents and have more perspective at the end of life is because we have seen what happens when people don’t prepare. This case and the article taught me much about my patients, my job as a physician, and mostly about myself. I’d love to hear about some of your thoughts about this topic.