DR. HOOK- Checking out: End-of-life issues hard to confront

look at this handsome devil!

Dying is so dreaded by most people that I wonder why we have so many expressions for it, like "I'm dying for a cold drink," or "I'd rather die than wear black shoes with a white belt!"

With all the talk about dying, you might think it would be easy to discuss it with your doctor. However, many doctors hate to talk about end of life issues, so we often wait until, well, it's time– like when the patient is hanging on by a thread. Also, in the outpatient setting, there just isn't that much time to talk about it. "So are you short of breath with that cough? Your blood pressure is a little high. Ever thought about end of life issues? Okay, here's your prescription, and be sure to quit smoking."

When I was a resident in LA, we were required to ask every single dingle patient about their advanced directives. Of course it was a selected population because you had to be pretty sick to be in the hospital. Still, you should have seen the faces on our really young patients.

"Doctor, is there something I should know?" 

I learned to address advanced directives in a matter-of-fact manner, kind of like the way Ellen DeGeneres talks. "So, if something drastic should happen– not that it will of course– and you couldn't communicate with us because– well you would be unconscious, not breathing, or something like that– what would your wishes be for us medical folks to do with you?" 

Okay, I'm not quite that Ellen DeGeneres.

But, really, it is difficult to know what a patient would want because there are too many variables that can enter into end-of-life issues for most people. For example, I'm 40 years old and pretty healthy. In my advanced directives, I state that I want to have quality of life should anything drastic happen to me. My significant other has medical decision-making power over me, but what about you? There's no way to know if certain things will leave you brain dead, in chronic pain, or seriously disabled.

So when I hear a patient tell me, "Doc, do everything possible to save my life, but if I'm left paralyzed by a stroke, then withdraw medical care. Or if it looks like I'm going to become paralyzed, then don't intervene and let me die." 

That request is so Las Vegas. You can't predict what will happen when a bad medical event occurs, nor can you gamble with the outcomes of treatment.

Now someone with a terminal illness or severe disease, that's a different story.

Resuscitation (CPR, IV medications, intubation, and/or electrical shock to the heart which are used in advanced cardiac life support) fails 99 percent of the time in a person with severe illnesses that include end-stage kidney failure, certain cancers, or end-stage heart disease. In these unfortunate people, if they do "make it through" initially, they usually struggle on for a few more days and then pass away. 

So if a person doesn't want to be resuscitated, they opt for a DNR status (Do Not Resuscitate). If a person is dying or dies with a DNR status, medical professionals do everything to make the person comfortable until the end. 

DNR doesn't mean, "Do Not Treat," which a lot of people fear will happen. It just means when it's time to go, resuscitation will not be performed.

I often wonder how I'm going to die. I may not last long enough to be the main guest on Oprah, but I just hope it's quick and painles– which means no news on Paris Hilton or Nicole Richie.


1 comment

My dear Dr Hong,
Many many patients linger much more than a few days. I noted you did not use the term "palliative" . Is that because it is usually in the NOT paid-for-by-insurance category of terminal care?