We All Must Die Sometime. We Just Don’t See It.

There was an exceptionally well-written piece published in the Washington Post this weekend.  I presume a hospitalist wrote it, which magnifies its significance.  In it, he describes the difficulties in caring for terminally ill patients.

As I read it, it reminded me of a story my dad told me several years ago.  His friend, I will call him Steve, was experiencing a great deal of stress because of his dad’s ailing health.  You see, his father had end stage dementia.

Steve relayed that his dad specifically communicated to him years earlier that he never wanted to experience the kind of death his father, Steve’s grandfather, underwent.  This, the heart wrenching and protracted death we all know on the wards: stepwise cognitive decline, erosion of ADL’s, and ultimately custodial dependence.  The patient is a shell of their former selves unable to interact or recognize family.

The irony and sadness was, Steve watched this same misfortune play out with his own dad.  Why you ask?  Because it happened so gradually, and so subtly, that there was no epiphanic moment to act on and deter.

I can only speak for men, but the idealized demise at 85—a round of golf, a fine meal, making love to the woman you love—and a painless death as you drift deeply to sleep—is a fool’s game.  Other than the errant politician, we have more fingers on one hand than accounts of that sort of celestial departure.  Steve’s experience is more commonplace, and it occurs that way just because.  It is life.

Overlay that anecdote with an encounter I had earlier this month.  I was with my resident team, on the wards, discussing another physician’s terminally ill patient.  As I began to deliberate on overtreatment and the ethics of end of life care, a radiation oncologist with whom I have a superficial, but cordial relationship joined in the discussion.  As he engaged, sentences such as “families need to know,” and “society must come to grips with our healthcare problem,” riddled his commentary.  It was the familiar, “America must have an adult conversation” oration.  The irony was, and this makes it so tragic, his patient was our focus.  His close proximity to the patient’s course, and long-term relationship with our subject blinded him. The irony was overpowering, and it gave us all pause.  Silence was the best tutorial of all.

Most of us, even the most experienced, believe we can navigate and identify points A to D.  We cannot.  The practice of medicine is A to B to C to D.  There is no instruction manual to render the spaces.

Next time you illustrate the dysfunctions of our system in a pedagogic role, ponder the above scenario.  Why? It might be you the team across the hall is discussing.

That is why resolving this problem is so damn hard.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

2 Comments

  1. Peggy Polaneczky,MD on February 19, 2012 at 8:51 pm

    This is a topic that requires repeated discussion, over and over again. Families need to discuss it early and often. You’ve put your finger on the problem – for so many, there is no single dramatic moment of choice. It’s a series of small, seemingly obvious decisions, day after day. that prolong the lives (and deaths) of so many of our elderly and infirm. We saw it with our mother, who was ready to go long before we were ready to let her. There were no major interventions, than god, but multiple visits to Er’s , short hospitalizations, tweaking of meds and urging to eat and walk and live to a woman who was ready to die.

    It was much easier with my grandmother, whose massive stroke allowed us the chance to let her go in peace, surrounded by her children and in a mercifully short time. She lived he life with joy until that day.

    Thanks for a great post.

    Peggy

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