{"id":510,"date":"2013-11-24T17:53:16","date_gmt":"2013-11-24T06:53:16","guid":{"rendered":"http:\/\/blog.panicola.com\/?p=510"},"modified":"2013-11-24T17:53:38","modified_gmt":"2013-11-24T06:53:38","slug":"how-doctors-die-showing-others-the-way","status":"publish","type":"post","link":"https:\/\/blog.panicola.com\/?p=510","title":{"rendered":"How Doctors Die: Showing Others the Way"},"content":{"rendered":"<ul>\n<li><span style=\"line-height: 1.714285714; font-size: 1rem;\">Key study on doctors preferences at end of life:\u00a0<\/span><a style=\"line-height: 1.714285714; font-size: 1rem;\" href=\"http:\/\/onlinelibrary.wiley.com\/doi\/10.1046\/j.1365-2389.2003.51309.x\/abstract\">http:\/\/onlinelibrary.wiley.com\/doi\/10.1046\/j.1365-2389.2003.51309.x\/abstract<\/a><\/li>\n<li>Nicholas A. Christakis (Yale) writes that few physicians even offer patients a prognosis, and when they do, they do not do a great job. Predictions are often overly optimistic, with doctors being accurate just 20 percent of the time.<\/li>\n<li>,\u00a0<a href=\"http:\/\/deathoverdinner.org\/\" target=\"_\">deathoverdinner.org<\/a>\u00a0is a website to help people hold end-of-life discussions at dinner parties<\/li>\n<\/ul>\n<p>Source:\u00a0<a href=\"http:\/\/www.nytimes.com\/2013\/11\/20\/your-money\/how-doctors-die.html?from=homepage&amp;_r=0\">http:\/\/www.nytimes.com\/2013\/11\/20\/your-money\/how-doctors-die.html?from=homepage&amp;_r=0<\/a><\/p>\n<div><\/div>\n<div>November 19, 2013 \u00a0<span style=\"font-size: 0.857142857rem; line-height: 1.846153846;\">By\u00a0DAN GORENSTEIN<\/span><\/div>\n<p itemprop=\"articleBody\" data-key=\"BIia\" data-num=\"0\"><span style=\"line-height: 1.714285714; font-size: 1rem;\">BRAVE. You hear that word a lot when people are sick. It\u2019s all about the fight, the survival instinct, the courage. But when Dr. Elizabeth D. McKinley\u2019s family and friends talk about bravery, it is not so much about the way Dr. McKinley, a 53-year-old internist from Cleveland, battled\u00a0<\/span><a style=\"line-height: 1.714285714; font-size: 1rem;\" title=\"In-depth reference and news articles about Breast cancer.\" href=\"http:\/\/health.nytimes.com\/health\/guides\/disease\/breast-cancer\/overview.html?inline=nyt-classifier\">breast cancer<\/a><span style=\"line-height: 1.714285714; font-size: 1rem;\">\u00a0for 17 years. It is about the courage she has shown in doing something so few of us are able to do: stop fighting.<\/span><\/p>\n<p itemprop=\"articleBody\" data-key=\"TsaTsa\" data-num=\"1\">This spring, after Dr. McKinley\u2019s\u00a0<a title=\"In-depth reference and news articles about Cancer.\" href=\"http:\/\/health.nytimes.com\/health\/guides\/disease\/cancer\/overview.html?inline=nyt-classifier\">cancer<\/a>\u00a0found its way into her liver and lungs and the tissue surrounding her brain, she was told she had two options.<\/p>\n<p itemprop=\"articleBody\" data-key=\"YcpSad\" data-num=\"2\">\u201cYou can put\u00a0<a title=\"Recent and archival health news about chemotherapy.\" href=\"http:\/\/topics.nytimes.com\/top\/news\/health\/diseasesconditionsandhealthtopics\/chemotherapy\/index.html?inline=nyt-classifier\">chemotherapy<\/a>\u00a0directly into your brain, or total brain radiation,\u201d she recalled recently from her home in suburban Cleveland. \u201cI\u2019m looking at these drugs head-on and either one would change me significantly. I didn\u2019t want that.\u201d She also did not want to endure the side effects of radiation.<\/p>\n<p itemprop=\"articleBody\" data-key=\"WDMSst\" data-num=\"3\">What Dr. McKinley wanted was time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean. But most of all, she wanted \u201ca little more time being me and not being somebody else.\u201d So, she turned down more treatment and began\u00a0<a title=\"Recent and archival health news about hospice care.\" href=\"http:\/\/topics.nytimes.com\/top\/news\/health\/diseasesconditionsandhealthtopics\/hospice_care\/index.html?inline=nyt-classifier\">hospice care<\/a>, the point at which the medical fight to extend life gives way to creating the best quality of life for the time that is left.<\/p>\n<p itemprop=\"articleBody\" data-key=\"DRGIah\" data-num=\"4\">Dr. Robert Gilkeson, Dr. McKinley\u2019s husband, remembers his mother-in-law, Alice McKinley, being unable to comprehend her daughter\u2019s decision. \u201c\u00a0\u2018Isn\u2019t there some treatment we could do here?\u2019 she pleaded with me,\u201d he recalled. \u201cI almost had to bite my tongue, so I didn\u2019t say, \u2018Do you have any idea how much disease your daughter has?\u2019\u00a0\u201d Dr. McKinley and her husband were looking at her disease as doctors, who know the limits of medicine; her mother was looking at her daughter\u2019s cancer as a mother, clinging to the promise of medicine as limitless.<\/p>\n<p itemprop=\"articleBody\" data-key=\"WicTut\" data-num=\"5\">When it comes to dying, doctors, of course, are ultimately no different from the rest of us. And their emotional and physical struggles are surely every bit as wrenching. But they have a clear advantage over many of us. They have seen death up close. They understand their choices, and they have access to the best that medicine has to offer.<\/p>\n<p itemprop=\"articleBody\" data-key=\"YhaYha\" data-num=\"6\">\u201cYou have a lot of knowledge, a lot of awareness of what\u2019s likely to come,\u201d said Dr. J. Andrew Billings from his home in Cambridge, Mass.<\/p>\n<p itemprop=\"articleBody\" data-key=\"DBaDBs\" data-num=\"7\">Dr. Billings, 68 and semi-retired, is an expert in palliative care, which can include managing pain, emotional support and end-of-life planning. He is also a cancer patient with a life-threatening form of lymphoma. Dr. Billings said that knowledge of what may be ahead can give doctors more control over their quality of life before they die \u2014 control that eludes many of us.<\/p>\n<p itemprop=\"articleBody\" data-key=\"RstMtp\" data-num=\"8\">Research shows that most Americans do not die well, which is to say they do not die the way they say they want to \u2014 at home, surrounded by the people who love them.<a title=\"Report from WRTV, Indianapolis.\" href=\"http:\/\/www.theindychannel.com\/news\/local-news\/medical-only-third-of-elderly-medicare-patients-die-at-home\">According to data from Medicare<\/a>, only a third of patients die this way. More than 50 percent spend their final days in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in\u00a0<a title=\"Recent and archival health news about nursing homes.\" href=\"http:\/\/topics.nytimes.com\/top\/news\/health\/diseasesconditionsandhealthtopics\/nursing_homes\/index.html?inline=nyt-classifier\">nursing homes<\/a>.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TinOtd\" data-num=\"9\">There is no statistical proof that doctors enjoy a better quality of life before death than the rest of us. But research indicates they are better planners. An\u00a0<a title=\"Abstract of the study.\" href=\"http:\/\/onlinelibrary.wiley.com\/doi\/10.1046\/j.1365-2389.2003.51309.x\/abstract\">often-cited study<\/a>, published in 2003, of physicians who had been medical students at Johns Hopkins University found that they were more likely than the general public to have created advance directives, or living wills, which lay out specific plans for care if a patient is unable to make decisions. Of the 765 doctors studied, 64 percent had advance directives, compared with about 47 percent for American adults over 40.<\/p>\n<p itemprop=\"articleBody\" data-key=\"PafTDA\" data-num=\"10\">Patients and families often pay a high price for difficult and unscripted deaths, psychologically and economically. The Dartmouth Atlas Project, which gathers and analyzes health care data, found that 17 percent of\u00a0<a title=\"Recent and archival health news about Medicare.\" href=\"http:\/\/topics.nytimes.com\/top\/news\/health\/diseasesconditionsandhealthtopics\/medicare\/index.html?inline=nyt-classifier\">Medicare<\/a>\u2019s $550 billion annual budget is spent on patients\u2019 last six months of life.<\/p>\n<p itemprop=\"articleBody\" data-key=\"WhbWhb\" data-num=\"11\">\u201cWe haven\u2019t bent the cost curve on end-of-life care,\u201d said Dr. David C. Goodman, a senior researcher for the project.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TasBaM\" data-num=\"12\">The amount spent in the intensive care unit is climbing. Between 2007 and 2010, Medicare spending on patients in the last two years of life jumped 13 percent, to nearly $70,000 per patient.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TeiTei\" data-num=\"13\">The evidence is clear, Dr. Goodman said, that things could change if doctors \u201crespect patient preferences and provide fair information about their prognosis and treatment choices.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"StcOdl\" data-num=\"14\">Sometimes that can be easier said than done, even for doctors. One day last month, as he sat through the first of several hours of chemotherapy at the Dana-Farber Cancer Institute in Boston, Dr. Billings said he had looked at statistical survival curves for his form of lymphoma.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TasTas\" data-num=\"15\">\u201cThere are some dots that are very, very soon, and there are some dots that are a long ways off, and I hope I\u2019m one of those distant dots,\u201d he said.<\/p>\n<p itemprop=\"articleBody\" data-key=\"DBkAhi\" data-num=\"16\">Dr. Billings knows how important it is to have that information. As a palliative care doctor, he has spent a lifetime helping people plan their final days. Also, he is married to a prominent palliative care doctor, Dr. Susan D. Block.<\/p>\n<p itemprop=\"articleBody\" data-key=\"AadIht\" data-num=\"17\">\u201cAs a doctor you know how to ask for things,\u201d he said. But as a patient, Dr. Billings said he had learned how difficult it can be to push for all the information needed. \u201cIt\u2019s hard to ask those questions,\u201d he said. \u201cIt\u2019s hard to get answers.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"TiaPha\" data-num=\"18\">There is a reason for that. In his book \u201c<a title=\"Publisher\u0019s website.\" href=\"http:\/\/press.uchicago.edu\/ucp\/books\/book\/chicago\/D\/bo3641373.html\">Death Foretold<\/a>,\u201d Nicholas A. Christakis, a Yale sociologist, writes that few physicians even offer patients a prognosis, and when they do, they do not do a great job. Predictions, he argues, are often overly optimistic, with doctors being accurate just 20 percent of the time.<\/p>\n<p itemprop=\"articleBody\" data-key=\"BwsYIh\" data-num=\"19\">But without some basic understanding of the road ahead, Dr. Anthony L. Back, a University of Washington professor and palliative care specialist, said even sophisticated patients could end up where they least want to be: the I.C.U. \u201cThey haven\u2019t realized the implications of saying: \u2018Yeah, I\u2019ll have that one more treatment. Yeah, I\u2019ll have that chemotherapy,\u2019\u00a0\u201d Dr. Back said.<\/p>\n<p itemprop=\"articleBody\" data-key=\"IRNDZh\" data-num=\"20\">In Raleigh, N.C., Dr. Kenneth D. Zeitler has practiced oncology for 30 years. The son of a doctor and the father of two doctors, he learned 18 years ago that he had a\u00a0<a title=\"In-depth reference and news articles about Brain Tumors.\" href=\"http:\/\/health.nytimes.com\/health\/guides\/disease\/brain-tumor-adults\/overview.html?inline=nyt-classifier\">brain tumor<\/a>, which was removed. When the tumor recurred in 2004, he took the conservative route and decided against an operation \u2014 the risk of\u00a0<a title=\"In-depth reference and news articles about Muscle function loss.\" href=\"http:\/\/health.nytimes.com\/health\/guides\/symptoms\/muscle-function-loss\/overview.html?inline=nyt-classifier\">paralysis<\/a>\u00a0was too great. Dr. Zeitler, his wife and their two children mapped out a clear medical path, or so they thought.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TiJIoj\" data-num=\"21\">Then in June, he woke up with the left half of his body paralyzed, after a low-risk\u00a0<a title=\"In-depth reference and news articles about Biopsy.\" href=\"http:\/\/health.nytimes.com\/health\/guides\/test\/biopsy\/overview.html?inline=nyt-classifier\">biopsy<\/a>\u00a0caused a hemorrhage in his brain. \u201cAs a physician myself, when treating patients, I listened to this inner voice,\u201d he said, but now he was mad at himself. \u201cInstead of just saying \u2018No, I won\u2019t do this biopsy,\u2019 I didn\u2019t follow my instincts.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"DZrIcm\" data-num=\"22\">Dr. Zeitler realized after his biopsy that saying no can mean more than turning down a procedure. It can mean dealing with something much harder: his family\u2019s expectations that he will do whatever it takes to live and remain with them.<\/p>\n<p itemprop=\"articleBody\" data-key=\"AtaIdn\" data-num=\"23\">As transparent as Dr. Zeitler was with his family about his clinical care, he had walled off his deepest fears about losing pleasure in his daily life. He has since regained most physical functions and says he has had another chance to talk to his family. \u201cAs much as they\u2019ll cry about me at every bar mitzvah and every wedding, I don\u2019t want to be there if I\u2019m just completely miserable psychologically and physically,\u201d he said. \u201cI\u2019ve seen that. I don\u2019t need that.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"DJTDJT\" data-num=\"24\">Dr. Joan Teno, an internist and a professor of medicine at Brown University, says that often, even families like the Zeitlers, avoid the difficult conversations they need to have together and with doctors about the emotional side of dying.<\/p>\n<p itemprop=\"articleBody\" data-key=\"WpfWdp\" data-num=\"25\">\u201cWe pay for another day in I.C.U.,\u201d she said. \u201cBut we don\u2019t pay for people to understand what their goals and values are. We don\u2019t pay doctors to help patients think about their goals and values and then develop a plan.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"BteAts\" data-num=\"26\">But the end-of-life choices Americans make are slowly shifting. Medicare figures show that fewer people are dying in the hospital \u2014 nearly a 10 percent dip in the last decade \u2014 and that there has been a modest increase in hospice care. At the same time, palliative care is being embraced on a broad scale, with most large hospitals offering services.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TACEEt\" data-num=\"27\">The Affordable Care Act could accelerate those trends. Ezekiel Emanuel, the former White House health policy adviser, has said he believes that new penalties for hospital readmissions under the law could improve end-of-life care, making it more likely \u201cwe make the patient\u2019s passage much more comfortable and out of the hospital.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"CtiTpf\" data-num=\"28\">Culturally there is movement too. For example,\u00a0<a href=\"http:\/\/deathoverdinner.org\/\" target=\"_\">deathoverdinner.org<\/a>, a website to help people hold end-of-life discussions, was started in August. The project\u2019s founder, Michael Hebb, said more than 1,000 dinner parties had been held, including some at nursing homes.<\/p>\n<p itemprop=\"articleBody\" data-key=\"TfdDMk\" data-num=\"29\">The front door at Dr. McKinley\u2018s big house was wide open recently. Friends and caregivers came and went. Her hospice bed sat in the living room. Since she stopped treatment, she was spending her time writing, being with her family, gazing at her plants. Dr. McKinley knew she was going to die, and she knew how she wanted it to go.<\/p>\n<p itemprop=\"articleBody\" data-key=\"InaIya\" data-num=\"30\">\u201cIt\u2019s not a decision I would change,\u201d Dr. McKinley said. \u201cIf you asked me 700 times I wouldn\u2019t change it, because it is the right one for me.\u201d<\/p>\n<p itemprop=\"articleBody\" data-key=\"DMdahw\" data-num=\"31\" data-sentences=\"2\">Dr. McKinley\u00a0<a title=\"Announcement by Case Western Reserve University.\" href=\"http:\/\/cwru-daily.com\/news\/school-of-medicine-faculty-member-elizabeth-mckinley-passes-away\/\">died Nov.<\/a><a title=\"Announcement by Case Western Reserve University.\" href=\"http:\/\/cwru-daily.com\/news\/school-of-medicine-faculty-member-elizabeth-mckinley-passes-away\/\">\u00a09<\/a>, at home, where she wanted to be.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Key study on doctors preferences at end of life:\u00a0http:\/\/onlinelibrary.wiley.com\/doi\/10.1046\/j.1365-2389.2003.51309.x\/abstract Nicholas A. Christakis (Yale) writes that few physicians even offer patients a prognosis, and when they do, they do not do a great job. Predictions are often overly optimistic, with doctors being accurate just 20 percent of the time. ,\u00a0deathoverdinner.org\u00a0is a website to help people hold &hellip; <a href=\"https:\/\/blog.panicola.com\/?p=510\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">How Doctors Die: Showing Others the Way<\/span> <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9,18,22],"tags":[],"class_list":["post-510","post","type-post","status-publish","format-standard","hentry","category-healthcare","category-meaning","category-policy"],"_links":{"self":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/510","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=510"}],"version-history":[{"count":2,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/510\/revisions"}],"predecessor-version":[{"id":512,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/510\/revisions\/512"}],"wp:attachment":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=510"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=510"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=510"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}