Responses to P. Chen, http://well.blogs.nytimes.com/2011/08/11/letting-doctors-make-the-tough-decisions/put Note Title - 0 views
started by Frederick Smith on 15 Aug 11
started by Frederick Smith on 15 Aug 11
/ SerPolUS_IDES/ Responses to P. Chen, http://well.blogs.nytimes.com/2011/08/11/letting-doctors-make-the-tough-decisions/put Note Title
started by Frederick Smith on 15 Aug 11
1 .
Old Colonial
Texas, now
August 11th, 2011
1:10 pm
What is critical here is the concept of long-term relationships between doctors and their patients, which most states are now destroying, espeically this one we have moved to - Texas. Never shrink from talking to your doctor about what you want, when, and if - if they brush you aside, never go back to them.
The bottom line, when faced with death is having the knowledge that one's doctor know what you want, and is wholly trusted for his/her competence, expertiese, ethical standards and that special internal spirit that directs their dedicated efforts.
When those things are in place, one can "let go" and either be healed, or pass on. I've been 'there,' twice.
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2 .
SKV
NYCer
August 11th, 2011
1:10 pm
Can't a family say, "Doctor, we'd prefer to leave the decision to your best judgment"? I know that used to be the only choice, or at least the default, but why can't it continue to be an option? If I trust my doctor, that's what I'd prefer.
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3 .
trader
NY
August 11th, 2011
3:09 pm
We do ultimately make the finally decision to stop.
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4 .
Cate
midwest
August 11th, 2011
3:09 pm
Wow, this is beautiful and a wonderful piece. I agree! I guess I can best illustrate this with an example involving our dog (sorry, I don't have any people examples):
Three years ago, our dog was dying after an internal injury, but to us he looked fine. Propped up by pain meds and externally normal, he wagged his tail and was lying still but eager to see us. He was subdued, but his eyes were clear.
His initial repair surgery had failed; they thought there was additional internal bleeding. Our decision was whether to continue with an exploratory surgery or to put him down.
The vet tech who came in with us gently explained that they thought his internal organs too perforated and infected to repair and that he might not make it through the second surgery, based on his current condition. She said everyone at the office felt our dog was not going to make it, but it was up to us as to what to do. She added that dying was not like going to sleep, but could be hard work lasting hours or days, with gasping for breath and pain.
So very sadly, we elected to put our dog down, but we were grateful for an honest response from the medical team. How could we know what to do? We thought, they regularly see these things, they could estimate likelihoods better. What do we know? We did not want our dog to suffer through additional procedures for no reason.
So it was very, very hard to do, but we had our dog put down.
I'm not saying people should be put down (that's a separate discussion), but we did get an honest discussion and OPINION from the medical people in this situation. I think that's all patients want. We can make our own decisions. But don't be afraid to tell us what you really think, even if we are a 90 year old who is stubborn and contrary, or an 60 yo that doesn't seem to think for herself...or whatever. Make it clear what you think.
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5 .
MB
CT
August 11th, 2011
3:09 pm
A nice point; but back to the case, I find the dialectic offered by the young doctor as being unrealistic. And, the indecision is not a weakness: committees can't make such a tough choice. That is why a proxy is needed.
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6 .
Dan Urbach
Portland
August 11th, 2011
3:09 pm
I've been in primary care practice as an internist for 19 years. I've been in this position as the doctor many times. A long term relationship with a patient makes a huge difference. However, like it or not, this type of practice is going out of business, and many patients who die in the hospital are being seen by hospitalists who don't know them. I don't think there's one answer to this problem. The situations are as various as are patients, families, doctors, nurses, and anyone else involved. I do have one suggestion that I think is very important: we need to teach patients and the public at large that death is a natural phenomenon, inevitable, often not a failure. Delaying death is often the wrong choice.
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7 .
Mark
Evanston, IL
August 11th, 2011
3:09 pm
For a number of years I have done ethics consultations in the Chicago area. I am not an MD but a PhD in Philosophy. I have found that patients' families are often surprised by three things when they talk with the physician. First, they are surprised by the complexity of the situation. Second, they are surprised by the uncertainty that often attends the situation (particularly in light of the advertising that exists promoting the wonderful solutions offered at major medical institutions). And, third, they are surprised that they are being asked to make the decision. Particularly in light of the three things by which they are surprised. What I have found is that the most useful thing to do is engage the family in a thorough discussion not only of the possible options in relation to treatment, but also in relation to the possible options of who, when and who the decisions should be made. But I have also found that these discussions can take a very, very long time, and can be very, very frustrating for all involved. The Obama administration recognized the need for such discussions (with no agenda) and the Republicans turned the concept into "Death Panels." I am still incredulous as to what happened. The whole thing was absolutely beyond my comprehension.
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8 .
jay pattelle
NY
August 11th, 2011
3:09 pm
Patient empowerment is a very healthy development. Ultimately we are accountable to our own selves for our health. As long as a doctor properly explains options, with pros and cons, we need to take responsibility for our own choices. We are free to choose to tell the doctor "Doc, please give me your preferred choice, and I will follow it." In earlier days, patient's destinies were in the hands of a doctor who may or may not have made the correct diagnosis.
A close friend overseas lost a relative because his doctor made a wrong diagnosis, and then proceeded to ram it down everyone's throat. The doctor was offended when, seeing no improvement, my friend calling in another specialist for a second opinion. The second doctor immediately corrected the diagnosis, but it was too late. If the patient had been empowered, he could have been saved.
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9 .
Muriel
London
August 11th, 2011
3:09 pm
There was no mention in this article of the legal implications for the doctor who fails to seek permission.
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10 .
Sherry Reynolds
Seattle, WA
August 11th, 2011
3:09 pm
We all know that informed and involved patients lead to better outcomes, higher quality, better RIO and higher patient satisfaction levels. Shared decision making vs the old style of paternalism is the goal for many if not all patients but very few providers and staff are trained or have the tools to provide it.
Studies also show that when patients are informed of their choices and educated about the risks and rewards they are much more comfortable making decisions so I would question the 2 out of 3 want their providers to make the decision since it might simply reflect a lack of time to educate the patient enough for them to make an informed decision.
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11 .
Lynn
New York, NY
August 11th, 2011
3:09 pm
We had a case when a demented patient came in from a nursing home. Her next of kin was 1000 miles away in Florida. We called him up and asked what he wanted us to do. The poor guy was completely blind sided he said do every thing. We hung up and called him back 20 minutes later. We said if we do everything she'd die in about a week, and if we did nothing but pain relief she would die that night, and that we wanted to do nothing. He agreed and was relieved to get permission to make this tough choice at the end of life for an Aunt that he had not seen in a number of years.
As a doc, I like to talk to my patients ahead of time without the stressors of pain and intubation. That way the family KNOWS they are doing what the patient wants, and not trying to guess. Does that mean I am in favor of death panels? I guess so.
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12 .
K S Venkataraman
Murrysville, PA
August 11th, 2011
3:09 pm
The doctor-patient relationship is more sacred than the one between the pastor (or priest) and the lay worshippers. Mercifully, in the non-Christian faiths, the relationship between the laity and the religious leaders is very tenuous, at best.
Very often, in serious cases, patients are given all the options and the pros and cons, and yet do not know how to go about making the choice. The belief system of the patients and the physicians also need to be considered.
Fortunately, most healthcare professionals -- I am not one of them -- are able to interact with patients coming from diverse faiths with great sensitivity.
I can understand the doctors' reluctance to participating in making the decision for the patients and their families, and live with the consequences of the decision. It is a terrible dilemma.
But that is why people treated doctors with so much respect... ... till we ended up a system driven by malpractice insurance companies and lawyers (some with medical degrees) suing doctors for "pain and suffereing" in addition to the other quantifiable medical errors.
This is, indeed, a complicated question with pharmaceutical industries and toerhs making medical gizmos making huge profits, while not willing to bear the responsibilities for their mistakes.
But still, I prefer to trust my doctor's sense of judgment and compassion.
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13 .
Jim Rosenthal
Annapolis, Md.
August 11th, 2011
3:09 pm
It's still a huge improvement over the time when no one told patients anything and they went to their deathbeds wondering why they felt so badly and were losing all that weight, if they were just fine, like everyone kept telling them they were.....
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14 .
Phil Rubin
Florida
August 11th, 2011
3:09 pm
Though not possible for everyone, an even better option is to use the internet to learn as much as you can about your condition. There are technical articles for doctors as well as lots of information laymen. Then you can have an intelligent conversation with your doctor instead of a one sided one.
http://www.youtube.com/watch?v=skqwaYPIc-Y
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15 .
Ted D
Providence, RI
August 11th, 2011
3:09 pm
Physicians need some legal cover to be willing to make the decision. Usually these are not life-or-death decisions but rather die now or die later after spending a lot of the tax payer's money. Non professionals rarely feel qualified to evaluate the value of further treatment and most welcome firm guidance from the MD (or RN)
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16 .
Bob
Maryland
August 11th, 2011
3:09 pm
I have watched 2 parents die both in NYC, both in acclaimed hospitals. Actually my mother essentially died in NY but I moved her to NJ, and a much better truly patient care centered hospital for the actual last breath. My father died of complications following colon cancer surgery in 1985. The doctors either didn't talk to each other or chose to offer us their conflicting opinions fully knowing that they didn't agree. I had to ask them all to convene in one room and explain it all to me, my brother and mother. It was complicated medical stuff and none of us had any medical background but eventually we came to understand - but only after we pulled the teeth. My mom died 24 years later. There were complications following her heart surgery but that wasn't what killed her. The NYC hospital told us not to worry about the fluid around her lungs because it was just routine post-op and she should get out of the hospital to avoid infection/complications and that she was ready for rehab. Not. After 2 or 3 days of suffering in rehab I moved mom to Morristown Memorial Hospital, One of the the first things the ER doc said was that I was right in bringing her in because she was very sick. And then their team mobilized. One doc was assigned just to coordinate. They had a patient liaison who gave new meaning to caring. It took a couple of days of tests but finally they concluded that mom was dying because her tricuspid valve was leaking and could only be fixed by surgery that she could not withstand. Thing was the NY hospital knew the tricuspid was leaking but thought it wasn't leaking so bad when they replaced the mitral valve. But when her breathing problems persisted t he NY hospital never looked back at the tricuspid. They never mentioned the possibility that her breathing problem, which was getting worse and worse, wasn't due to typical post op fluid but to a problem they'd forgotten about, a problem that Morristown quickly found.
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17 .
mauricioboteromd
stuart,fl
August 11th, 2011
3:09 pm
As a nephrologist, kidney doctor, many times i have had these discussions about end of life issues with families. It is always quite difficult but I would like to share things I have leard through the years.
First is a physician dealing with a terminal patient is treating not just the sick one but the family too. Dealing with a dying patient can leave scars in a family. Second, these discussions are self fulfilling, we are not discussing actions outside our control, we are discussing and modifying the situation at the same time. Third, one can never rush these decisions, hospitals have a team of nurses, social workers, trained to rush families into these discussions because it is in the hospital financial interest. Fourth, use the recent history of the patient, when somebody keeps being discharged and coming back to the hospital with acute illness it is a good signal that we have used all our resources and it is time to quit.
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18 .
tough old bird
Virginia
August 11th, 2011
3:09 pm
I can't understand why people can't face the fact that someday they're going to die and have wills, powers of attorney, medical directives and living wills done when they're young. They can always change them should their attitudes change.
I was able to convince my mother to write all of the above documents by doing it for myself at the same time when we were going to take a trip together. A good time to talk to your parents about having their papers in order so that their wishes are followed when something happens. They feel more comfortable if you are doing it for yourself at the same time.
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19 .
Josh Hill
New London, Conn.
August 11th, 2011
3:09 pm
When we had to decide whether to put my grandmother back on a respirator or let her die, I asked the doctor what he would do if it were his grandmother. He said unequivocally that he would let her die. And that's what we did.
In a situation like that, I am grateful for a doctor's clinical experience and expertise. Such decisions must ultimately be up to the patient and family -- within legal and ethical bounds, no one has a right to tell them what to do, unless they cede authority to the doctor. But in my experience anyway, a doctor's opinion is welcome.
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20 .
Craig
Jersey City
August 11th, 2011
3:09 pm
I think what often happens is that doctors and patients and families--in times of great stress--naturally blur the line between science and ethics. A doctor is in no position to make an ethical decision regarding what is good, or bad, for a patient. Likewise, most families are in no position to form a scientific assessment of a loved one. Out of an abundance of caution, doctors sometimes do not provide families and patients with a truthful assessment of the patient and his or her likely response to treatment, for fear that this will be "telling the family and the patient what to do." This is not, though, telling the family what to do. It is only, one hopes, the truth, within a reasonable degree of error. And whatever the truth, it is then up to the family or patient to decide what to do with that information.
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21 .
DrSam
Philadelphia
August 11th, 2011
3:09 pm
Times New Rom