Heroic measures cannot cure how people want to live their lives

I was working in the Intensive Care Unit (ICU) the other day and as I counted, I found that more than half of the patients there, for lack of a better term, brought the condition upon themselves.

I sound harsh, but there was no better way to put it. I was taking care of Mrs. B, a 60-year-old lady with COPD who called EMS for shortness of breath. As EMS readied to take her to the hospital, she said, “you all are gonna have to wait until I finish my cigarette.” She has been intubated many times for COPD exacerbation, visited the ICU a hundred more times. She said if she got out, the first thing she would do would be to smoke a cigarette, but she did not believe she would make it this time. After multiple weeks on continuous BIPAP with spurts of intubations in between, she told us to quit and let her die.

Looking around the ICU that day, there were multiple stories like her – a cirrhotic who was actively drinking despite his varices bleeding to death after 30 units of various blood products that turned out to be futile, a 20-year-old diabetic with recurrent admission for diabetic ketoacidosis who left against medical advice the minute he found out he would not get any intravenous dilaudid, a gentleman admitted with pulmonary edema every 3 days because he refused to go to dialysis.

As days passed, I realized that these patients were common – I was being trained to undo what these people did to themselves, so that they can leave the hospital to do it some more. Some has hurt themselves so many times it could not be undone, despite many resources wasted and much money spent. I watched 30 units of blood passed through one end of our patient only to flow right out another, and I wondered if there was not someone else out there who would not undo our efforts, our blood products, our precious resources.

More importantly, I wondered if we could ever draw a line, where we say enough is enough, where we say you do not get a second chance at life so that you can just kill yourself in the end, where we say there comes a point when heroic measures cannot cure how people want to live their lives. Before medical school I always thought that medicine was made to promote health, but in the light of reality I have learned that my job in the ICU today is really to prolong death, so that in the end people can crash and burn a bigger flame, taking much needed resources with them.

Mrs. B knew in her heart that smoking would be her death, yet smoking was the one thing she pined for. I wanted to tell Mrs. B that if she wanted to die, I was in no place to stop her. I might have had a shot as her primary care doctor before she picked up her first cigarette, but that time is long passed. In the end when the BIPAP came off, she became unconscious and passed away peacefully. I wanted to ask if we should have stopped sooner, maybe two intubations ago, but I will never know.

 “angienadia” is an internal medicine physician who blogs at Primary Dx.

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  • rjp225

    This is a tough issue, and the stories are certainly sobering, but don’t you have to keep sight of the fact that in the end, we’re all going to die.  Medical care isn’t about preventing death; it’s about improving the quality of patients’ lives and perhaps prolonging those lives.  The fact that a patient continues self-destructive behavior doesn’t mean that the treatment and resources have been “wasted.”

    • killroy71

      Well that’s a lofty ideal, and might work if these people were paying the full cost of the medical care they are getting to maintain a quality of life they are bent on destroying. But they aren’t.

      The rest of us are substantially helping them bear that financial burden, and it’s bankrupting us as a country, stifling wage growth and the health of other economic sectors and, if experts are to be believed, threatening future prosperity. Except for the health care sector – that will continue to thrive.

      • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

         I understand that frustration, but linking the behavior to cost of care is not substantiated by facts. For example, someone who dies of a heart attack or cirrhosis at 50 costs a lot less than someone who lives till 90 and spends last 10 years with Alzheimer. Prevention is a good thing for an individual, but it does NOT save money. It was shown by study after study after study.

        • John Henry

          Both the 50-year-old cirrhotic who spends four of the last six months of his life in hospital and the 80-year-old who spends 10 years in nursing home care with Alzheimers cost the society for their care. Who pays depends on assets, private insurance, or public funds as the facts may depend. But that misses the point. The OP is asking why we should continue to provide costly care to people who are very clearly indifferent to the efforts to restore them to health and who actively work against those efforts. The decision to care for those patients, and the costly interventions required have consequences, not least of which is that they compete for resources needed elsewhere. The American culture of entitlement, and the expectation by many that no one be deprived of any needed lifesaving service, no matter their personal resources, has never really been forced hard against the reality of limited public resources, but that luxury of denial is coming to an end.

        • MuddyWaterz

          Stop quoting “studies” unless you are willing to post the references.

    • http://twitter.com/angienadia angienadia

      You are absolutely right – this is very tough and I can’t put my foot down one way or the other. We can’t put a price on gaining a day or two for patients to say goodbye to their families, but for these patients who come in over and over asking to be saved while actively killing themselves makes for a very difficult dilemma for physicians. I’ve poured blood into many bleeding cirrhotics who are actively drinking and after a while I’m just simply angry – so much was sacrificed for a bag of blood and it just goes through one end to come right out another – a complete waste. Imagine an extreme example where a liver transplant goes to a drunk who fails to take his meds and continues to drink – there are two small children somewhere else who could use that one full liver. I really wonder if one day we can say “if you don’t plan to stop smoking and you’re in respiratory failure from COPD, we’re not going to intubate you because you will die when you leave the hospital”

      • Fighternotsurvivor

        Are there any limits to what medical services you would like to see denied to people who bring their illness or medical emergency upon themself? Fat people who won’t stop eating unhealthy, should we limit them to two heart attacks before we decide to write them off? If a person with a mental illness won’t take their meds, and makes more than one attempt to
        Commit suicide, should we just let them bleed to death next time they slit their wrists? If a repeated
        DUI offender gets into a wreck and needs treatment, do we just send him away if the ER is busy?
        Your reasoning would probably kill off a large chunk of society. But, I get the feeling from your replies your logic won’t stretch far enough to see that. I hope your disgust with patients who you deem deserving to die eases and gives way to some compassion. Most of all I hope your questioning of the fairness of it all isn’t something you act out on patients. I don’t know whether it is God’s job to decide, but I do know it sure as heck isn’t yours.

        • http://dinosaurmusings.wordpress.com/ #1 Dinosaur

          How’s this: pick a number. Three strikes? Five? Ten? Doesn’t matter. Pick a number, then authorize the ambulance to leave them at home (so they can finish their cigarette.)

        • John Henry

           Medical resources are finite. Let me ask you which which services you think not only you but members of your family and your community can do without because they are no longer going to be available because of exhaustion of resources. It is easy to whine about the entitlement of everyone to due consideration, the self destructive and wasteful and those not, but it is a lot harder to make the choices about what gets stopped because too many people waste what is provided. Will it be a dialysis center or a wound care clinic? A pediatric ICU or a stroke rehab unit? More is coming.

      • http://twitter.com/ButDocIHatePink Ann Silberman

        My husband gives blood and he’s past the gallon mark now.  You know what he sacrificed? Lunchtime.  Do you think he’s sitting there obsessing whether his blood is going into a “bleeding cirrhotic” or not?  No.  He has done his job to society and given what he can.  You should do the same, young lady.  You are too immature and thoughtless to make life and death decisions and you do not have that right OR obligation.  Do what you have been trained to do and leave the judgment and attitude at home; like a decent doctor.   If you are unable to muster sympathy for those who have made life choices you do not agree with, than I suggest you find a different outlet for your skills and talents.  Speaking as a very sick patient, doctoring requires a certain amount of empathy along with schooling. Whether you are sick for nothing you did, like me, or sick because you have made stupid choices, like your “cirrhotics” at the end of the day, these are suffering people, human beings, who are depending on you for care.  And, coming at them with an attitude of disdain is pure poison and they will know it.  Is that what you want your legacy to be as a doctor?  Scaring patients with your disdain and disrespect in their last moments?

  • mark ard

    I think this is a hard reality for medical professionals. I spent a few years in prehospital care before getting into medical school picking up people like this, yet many of my classmates have a fantasized hope of “healing” people. While that’s part of the job, what’s more important (and of which healing is a subset) is managing the quality of life of a patient. There are aspects of the job that are amazing and unique to the profession, but it is also a job. Someone is paying for your service. Patients expect you to deal with them as they are. You almost need a split personality to handle it though. On one hand you have to be afflicted on some level to help these people at whatever stage you meet them, whether primary care or in the ICU. On the other hand, you need to be immune to that side of the equation to treat objectively. Or so it seems. What the hell do I know though. Great article.

  • CBRN

    Thank you for your work as an ICU nurse.  ICU care allowed my grandmother to recover enough at one point in her terminal illness to allow us six more good months.  I am very grateful for the care she received.    Thank you for working through these frustrating experiences to do all the unquestionable good as well.

  • Payne Hertz

    Maybe you should learn about addictions and how hard they are to quit, then you will begin to understand the people you are so divided on as far as whether they should live or die is concerned. Your problem–and it is your problem, not your patients–is that you expect 100 percent perfection from human beings, and failing to get it you start triaging in your mind who ought to die and who should live. If we as a society ever demanded half the perfection of doctors that you demand of your patients, none of you would be working today.

    Unfortunately, you are so heavily entrenched in your institutionalized thinking you fail to realize just how appalling articles like this are to those of us who don’t share your world view.

    Take your patients as they are, do the job you are paid to do and stop playing judge.

    • http://twitter.com/angienadia angienadia

      Hi Payne,

      I can tell you’re not a doctor.I do not expect 100% from any human being, and I have learned quite a bit about addiction – I have patients on Suboxone who have turned their lives around. What I wrote about is really far from being my problem – the ultimate problem is with the patients themselves, who really despite our heroic measures will definitely die if they don’t stop actively destroying themselves. I am not triaging – the patients already decided their own fate – almost all of the ones I’ve talked to *know* that alcohol and cigarettes will be their death, and most of the time they are absolutely correct. 

      I don’t have an answer, but the dilemma is real – we don’t have unlimited organs, blood, resources. So the question becomes – is there a time when instead of throwing heroic measures at patients, we should sit down and ask the patients how important alcohol is to them, and if they want to die drinking, maybe that’s the choice we have to respect.

      • Payne Hertz

        “I can tell you’re not a doctor.”

        What gave it away, my lack of willingness to see people die to save money?

        “I wondered if we could ever draw a line, where we say enough is enough, where we say you do not get a second chance at life so that you can just kill yourself in the end,”

        Let’s not mince words about a statement like this. There are only two possible conclusions from this question: we either treat people who you and other doctors have decided have caused themselves to suffer, or we let them die. The idea that someone should be allowed to die because you, in your omniscience, have determined they brought it on themselves is utterly appalling. That leaves the first option the only civilized one and renders your agonizing over this issue moot.

        I am starting to wonder how many patients who die every year as a the result of “bad outcomes” have really been allowed to die or maybe given a little push in that direction by doctors with attitudes like yours. There is something deeply wrong in the a system where the only way doctors can figure to save money and preserve resources is to deny people treatment.

        If you are truly worried about saving money, I would think the $250-500 billion dollars in medical fraud that occurs every year would be a good start, not to mention the waste and inefficiency of the insurance industry. The primary drivers of cost in the American medical systems are profit, fraud and waste, and we could dramatically reduce all of these by switching to a nationalized, genuine non-profit medical system. Another driver of cost is the huge number of people killed and injured by the medical profession every year. You can do your part to contain costs and improve safety by reporting bad doctors and fraudulent practices at your hospital and in your community.

        • http://dinosaurmusings.wordpress.com/ #1 Dinosaur

          Geez, Payne, did you even read the response: 

          So the question becomes – is there a time when instead of throwing heroic measures at patients, we should sit down and ask the patients how important alcohol is to them, and if they want to die drinking, maybe that’s the choice we have to respect.

          She’s not saying that doctors should make unilateral decisions about treatment, rather that we should include patients in these difficult discussions and actually respect their wishes. 

          • Payne Hertz

             Her comments (and yours) are clear enough. Spare me the spin.

            “How’s this: pick a number. Three strikes? Five? Ten? Doesn’t matter.
            Pick a number, then authorize the ambulance to leave them at home (so
            they can finish their cigarette.)”

      • Payne Hertz

         How do you make this determination, BTW? I know a girl who is an ex-heroin addict who got HIV from the needles. No doubt in your view she brought this on herself and should be allowed to die. But a humane person might think otherwise on hearing her story. As a young girl she was repeatedly raped and beaten on a regular basis by her stepfather. Later, she had a friend blow his brain outs with a gun right next to her, with his brains and blood splattering all over her. The cops kept her there for hours questioning her to be sure it wasn’t a murder and wouldn’t let her clean up. Needless to say she suffers from PTSD. I would think that would be enough right there to drive anyone to drinking or drugs to kill the trauma and pain.

        She later got into a motorcycle accident where she broke her hip and multiple bones and was left in horrific pain after the surgery by doctors who refused to treat her pain. She was forced to turn to street heroin to treat her pain (40 percent of injectable heroin users are chronic pain sufferers) and she contracted HIV from a shared needle. She also did 6 months in prison for possession of the only thing she could avail herself of to treat her pain. I can only imagine what additional hell she went through to obtain the drugs because of the insane war on drugs.

        From what I can see, just about everyone but her is responsible for the hell she suffered, from her rapist stepfather, the cold-hearted doctors who considered her unworthy of pain relief, to the drug warriors and puritans who don’t allow people to obtain pain relief outside the medical industrial complex without putting their lives and liberty at risk.

  • http://twitter.com/ButDocIHatePink Ann Silberman

    As I, a metastatic breast cancer patient, lay in ICU with a terrible case of c-diff, no doubt brought on after my liver resection surgery by some doctor or nurse who was careless enough not to wash up between patients, I had nothing to do but sh*t and listen to medical “professionals” talk outside my door about patients.  I was appalled at the uncaring attitude that I heard then, and see in your note.  I hope you are never my caregiver.  I didn’t do anything to get my breast cancer; I’m thin, a non-drinker, non-smoker, healthy eater.  But even if I had, what is the harm in a little kindness?  If not for the person dying, than for their family who had nothing to do with it?  

    My mother was one of those cirrhotics you refer to and yes, I am angry she drank herself to death and as an active alcoholic my entire life, she was an awful mother.  But, I still hope that she was treated with kindness at the end. I don’t know what made her that way and neither do you.   Really, that is all you have to give in life, is a little kindness and understanding.   That is what I gave to the careless medical professionals who made me almost lose my colon and life with c-diff; you should try the same.

    You do not get to play with life – decide who is worthy of living and who is not. You, as a doctor, simply cannot know the entire story of a life in the time you see them.

    I strongly recommend that you seek another career if you truly feel that you have the power and knowledge to decide which life you see is unworthy. You have neither.

    • cervelo58


    • Allie Vassilieva

      Do you have actual proof that your case of C-Diff was caused by “some doctor or nurse who was careless enough not to wash up between patients” ?  Most often C-Diff is caused by an overuse of broad-spectrum antibiotics, as well as chemotherapy, both of which wipe out natural body flora (i.e. “the good bacteria” that live in your gut, on your skin, etc.) allowing superinfections like C-Diff to rage out of control.  The article does not mention a single cancer patient, you are twisting words, trying to make the author look like a monster who blames cancer patients for their disease.The article also does not advocate an uncaring attitude, the most caring nurses I’ve met worked in a hospice setting, they are absolute angels, allowing patients to die comfortably, taking care of the patient as well as the family.  Anyone can be kind without using every medical tool at their disposal to prolong some poor soul’s painful terminal illness.You advocate for understanding but you have no idea what it’s like to watch people undo what you have done trying to help them.  Your mother drank herself to death but did you yourself take her to the hospital EVERY SINGLE TIME?  Did you draw her labs every time, waiting to see her BAC or LFTs?  Did you start her banana bag, waiting to see how long it takes her to come out of this alcoholic stupor while her kids sat by her bed crying & holding her hand?  Did you have to bring her into the back of the ER because she was unconscious ahead of all the other people who have been patiently waiting for hours to be seen?The article doesn’t advocate playing with life to see who is deserving of precious resources, it merely suggest that if people do not want to do anything to help themselves then we should stop pushing medical care on them & allow them to die, whether it’s in a drunken stupor at home or gasping for breath while they smoke the last Marlboro.

      • http://twitter.com/angienadia angienadia

        Thank you, Hospice-Auspice – you’ve said everything I wanted to say and articulated it much better.

        • http://twitter.com/ButDocIHatePink Ann Silberman

          I have no proof of how I for c-diff.  I was in the hospital for my resection, given antibiotics there, went home and got a massive case of c-diff.  I don’t know for sure what happened and neither does the writer of the article, which was my point. She or he says that she knows enough about people in the time in the ICU, and she doesn’t know a damn thing.  She can’t even call the patients by their names, or anything human.  They are cirrhotics and diabetics – not people.   It is sickening it hear somebody in medicine talk like this but I fear it’s all to common.  Nobody has a right to judge what resources should go where.  Your “heroric” efforts are not heroic when they are meted out with such judgment and disdain.

          • Payne Hertz

            Well said, Ann.

          • Luke G

            It seems like you’re a person who quickly leaps to conclusions that other people are ignorant and malicious.  You blame doctors for your c-diff but have no proof.  You read this article–which doesn’t even take a stance, but rather expresses the author’s conflicted feelings–and conclude the author is uncaring, immature, and thoughtless (which I assure you is far from the truth).  And you have the gall to publicly deride the author and your doctors.  You say the doctors are jerks, but you’re the one coming off as the jerk here.

            You seem to deny the fact that we only have a finite amount of resources and somehow they need to be allocated.  Unfortunately, no matter how much one wishes it isn’t true, we can’t spend unlimited money on every patient trying to extend their life.  You may find the discussion morally unpalatable, but it needs to happen, and that’s what this article is saying. 

            “Nobody has a right to judge what resources should go where”; well what alternative are you proposing for resource allocation?  Something nonjudgemental like alphabetical order?

      • Payne Hertz

        “…it merely suggest that if people do not want to do anything to help
        themselves then we should stop pushing medical care on them & allow
        them to die,”

        Yeah, that’s the point, along with the condemnational attitudes and the lack of understanding of how hard it is to quit an addiction, particularly for people who are in horrific pain and hovering on the edge of death.

  • http://www.facebook.com/people/John-Davidson/100003717458506 John Davidson

    Adenoviruses Cause COPDIt has always been obvious merely from looking at the scatter plots in old studies of lung function that, among both smokers and nonsmokers, certain individuals were distinctly abnormal. They had much higher rates of loss than the others. There was a higher proportion of abnormal individuals among the smokers, and, by ignoring these individual differences and lumping together all smokers versus all nonsmokers, the anti-smoking ideologues falsely implicated tobacco as the cause of chronic obstructive pulmonary disease (COPD).
    COPD IS A SYSTEMIC, NOT LOCAL, DISEASEMitochondrial Abnormalities in COPD include tissues with no exposure to cigarette smoke
    Systemic effects of COPD. M Decramer, F De Benedetto, A Del Ponte, S Marinari. Respir Med 2005 Dec;99 Suppl B:S3-10. “Chronic obstructive pulmonary disease (COPD) is characterised by a range of pathological changes of the respiratory system, including airflow limitation secondary to structural changes of the small airways and loss of alveolar attachments, inflammation, ciliary dysfunction, and increased mucous production. COPD also has significant systemic consequences…. Although improving lung function and disease symptoms have been the main focus of COPD management, these parameters alone do not reflect the full burden of disease. More recent endeavours have highlighted the potential role of addressing physical limitations imposed by systemic alterations. It is evident that systemic manifestations are common in COPD. Indeed, many patients demonstrate a gradual and significant weight loss that exacerbates the course and prognosis of disease. This weight loss is often accompanied by peripheral muscle dysfunction and weakness, which markedly contribute to exercise limitation and impaired quality of life.”
    Decramer – Respir Med 2005 abstract / PubMedhttp://www.smokershistory.com/adencopd.htm

    • pattiern

      …and vaccines cause autism, and cough syrup cures fibromyalgia, and morgellons are very, very real….

  • cmac611

    Individuals who act responsibly but get dealt a ‘bad hand’ should be able to get affordable insurance and health care.  Unfortunately, are broken ‘profit driven sick care system’ is over run with irresponsible individuals that feed this ‘pdscs’ … the responsible (a clear minority) get to ‘share’ the cost of bad behavior.  We need to penalize bad behavior, not subsidize it. It seems the only motivation for irresponsibles is money … $8/gal gas (like Europe) means smaller cars, $10/liter of soda means less diabetes? Let just call it a ‘good behavior’ tax!

    • Payne Hertz

      How do you know whether people are “responsible” or not, and who gets to be the judge of that? How do you define “responsible?” Who gets to determine how everyone else is supposed to live their lives? Doctors? What exactly qualifies them as paragons of virtue?

      Person A eats a diet of pure junk food, drinks whiskey, smokes, snorts cocaine and has unprotected sex but remains thin and never reveals her lifestyle to a doctor. Person B struggles with her weight but eats healthy food and engages in none of these destructive behaviors. Why should person B pay more for health care than A? Why should either be denied treatment and allowed to die? What makes you think anyone is capable of judging a person’s entire life based on a few minutes contact in a doctor’s office?

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

       Your claim that bad people with bad behavior actually cost more money over the live time vs people with good behavior is your PERCEPTION. There is not a single study that shows that prevention saves money, quite the opposite. In fact there was a study that showed that responsible people cost more. A runner who is slim, may have a lot of injuries. An obese person may die 20 years sooner and avoid years of dementia. We are all mortal. We are all likely get sick at the end, Even preventive care costs add up over the years. So while it’s great to promote good behavior and it may increase to some extend the number of years one is productive, don’t make claims about costs that go against the studies.

      • karen3

        I remember twenty years ago talking to a  pulmonologist in China. He explained to me that the government strongly encouraged cigarette smoking because that way people died pretty efficiently about the time they stopped being able to work.  It cut down substantially on pension costs.  

  • karen3

    If you are spending your time counting how many of your patients “brought it upon themselves”, please for gods sakes, quit medicine. You are a judgmental creep who has no business having responsibility for other people’s lives. How bout in exchange  for your being an insufferable jerk we in society cut off your food and water.  Seems sensible to me.  

    • karen3

      To put a finer point on it, my suspicion is the most of society would find a kindly grandmother, who was always generous with her time and decent to all, but who had a nicotine habit, to be of far more value as a member of society than a nasty, snarky ICU nurse. If you are going to propose offing members of society based on their perceived “worth” don’t be shocked if folks like you go first, not last. I’d rather be a smoker with lung cancer that to be you.

  • http://twitter.com/angienadia angienadia

    Again, I’m not judging or playing god. All I’m saying is there’s a value in a discussion between healthcare professionals and patients, when we say what patients are asking might not make sense. If a bleeding cirrhotics come in massively GI bleeding (regardless of etiology), the odds are they will die if they continue to drink, *if* they actually survive the hospitalization, so what’s the point of doing massive blood transfusion? If they choose that they want to die drinking, I would be playing god if I try to get in the way. Heroic measures won’t cure alcoholics – counseling might, but again doctors are not god so we’re not always successful. 

    Mrs. B, in the article for example, she fully understands. She knows smoking will literally kill her as the immediate cause of death (not adenovirus or mitochondrial abnormalities when she smokes like a chimney) – and she knowingly CHOSE it. And she realizes that what we did was pointless, because she knew she would eventually die from smoking sooner or later, so after a while she just told us to stop. I think she had perspectives because she’s been intubated so many times, but not all patients have the same insight as she did, and this is when a discussion can be helpful.

    • http://twitter.com/ButDocIHatePink Ann Silberman

      You are playing God in that post.  You, above all, have decided who is worthy of living and who is not.  You can’t even call them people, they are “bleeding cirrhotics” which is a nice way to dehumanize somebody.  What  is the point of doing the blood transfusion?  What if they DO quit drinking, survive, go on to live a remarkable life?  What if they survive long enough to make it up to a family member? What if they choose to drink and die?  What gives YOU the right to decide that they aren’t worth treating?  

      There may be some value in this discussion but now when the person who starts  it so so very clearly disdainful of the people they are charged to care for.  You said it sounded harsh in your first paragraph and it does.  You are harsh.  Again, I hope you are not working my neck of the woods because I don’t want you anywhere near me.  

      • pattiern

        Lady, taking your bleeding liberal heart into a hospital and spend one week in the emergency department and another in ICU…then come talk to us.

        How are you going to feel when your teenager who has been in a car wreck bleeds to death becasue all of the A-negative blood went to the alchololic an hour ago?   Or when your spouse with avian flu can’t get a ventilator because Mrs. Three Packs a Day is using it?

        Bet that would change your tune pretty quickly as well?

        • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

          I hate smoking more than anything, but what if this Mrs Three Packs a Day a Nobel prize-winning scientist who in the next two years is destined to come up with some huge new research that will benefit humanity?

          • karen3

            Maybe instead of looking at what people have brought upon themselves, why don;t we ration care by how kind and decent a person has been?  And if they have posted nasty posts how much they look down on other people, they get shorted the blood, the vent, etc. Can you just mark you down as a person who deserves no medical treatment?  

        • Payne Hertz

          How would you feel if your teenage daughter came in bleeding into the ER and had to deal with a nurse like you who despises her because she smokes or is overweight? What makes you so damned pure?

        • http://twitter.com/ButDocIHatePink Ann Silberman

          Dude, I am not a liberal, I’m a conservative, but it doesn’t matter to this conversation.  And, sadly I have spent time in ICU and the emergency department as a patient, since I have terminal cancer.  I am well aware of what goes on.  Your argument is ridiculous but it’s what I would expect from somebody whose first sentence begins with name-calling (and yes, I think “liberal” is an insult.)   

          Perhaps every doctor or nurse who has a drink, smokes a cigarette, takes a pain pill, puts on a few pounds, makes a dosing error, forgets to wash his hands, or gives mistaken advice should have a public mark on their record.  Every doctor or nurse who makes a serious mistake, and that would be all of them, should be thrown out of the profession.  After all, shouldn’t they be setting an example?    

          How many fat doctors and nurses do I see? How many with yellowed, smoker’s teeth?    Why are they allowed to treat patients?   How many are drinkers?  How many make bad financial decisions?  How many have IQs under 130?  How many waste time and resources during the course of their jobs?  How many protect others in their profession whom they know shouldn’t be working?  How many make as many typos in patient notes as this person did in her article, maybe causing a medication error?

          Worry about your own profession rather than the people you have sworn to treat, and to whom you should “do no harm.”  Treat them and let them be and if they come back and you don’t like it, than go find another job.  Good luck finding one where everybody you come into contact with is perfect.  

          Yes, there should be a conversation about how best to manage hospital resources. But this one isn’t it.  Because, the original poster came at the topic with her position being that she was above reproach and the people she treats deserve neglect because in her shallow mind and limited life experience, somebody who doesn’t do what she thinks is right is not worthy.  She is on a mighty high horse.  

          We all hope our doctors enter the profession because they care about people and want to help, even the seemingly less deserving.  It’s an honored profession,with people we are supposed to be able to confess to to without being judged and one where we should be encouraged to change but treated with respect if we don’t. We want to believe that doctors think all life has value.   If the person who posted this topic represents all new young doctors coming up, than God help us all.  Money over life, that’s what we don’t need in our doctors.  This person should get into hospital administration and quick because the exam room is no place for this kind of person, who doesn’t like people who don’t meet her standards.

          Frankly, I think she’s just a privileged Yalie who has never really had a hardship in life and so approaches the world with a very black and white attitude, and that is going to make for a terrible doctor.  

          How is that for judgment?  At least I don’t hold the power of life and death over her.

        • Sapphire Storm

          Come on…stop being an idiot. How sickening your words are. Is one supposed to hole up at home in his sad decline just in case something he doesn’t even know about might happen? Please. The deficits you mention are the problems of a poor health care system, not an individual. Yes…Let’s let the alcoholic die because just in case someone else needs the bed. Why don’t you go live in the Middle Ages (or before). Your thoughts are repellent.

    • Sapphire Storm

      Ugh! This is sickening! Do you ever think that the person without extensive education just might not have the resources that you do? Do you think that maybe chances are their life circumstances might have led that person to addiction and not really understanding the value of his/her life? So if YOU decide that person doesn’t value his/her life enough, then that person does not deserve treatment? Who will decide? What metric will be used TO decide? How about showing some humanity? Medical care is not for robots; it’s for human beings and all their individual struggles and problems. Sorry, but that is the truth. Don’t be disgusting.

  • pattiern

    Thank you…thank you…THANK YOU!

    I see the same insanity as a nurse, and I understand addiction and the genetic compoments to disease (such as small cell lung cancer, which picks on NON smokers, and some cardiac problems are related to DNA, not bacon cheeseburgers and inactivity)   BUT

    …as this doc says, about half of the patients have self-inflicted or at least self-exacerbated illnesses.  Hey, its a free country, but why does EVERYONE ELSE have to pay for their poor choices?

    We need some sort of two-tier system for those who do not want to  change health habits, so they comfort care but not four months a year in the ICU!

    • Payne Hertz

       What makes you the judge of whether someone’s illness is self-inflicted or not? You think you can judge a lifetime of behavior by a few minutes in the ER? Why are we as a society paying for medical  practitioners who would rather judge people based on presumption and ignorance than treat them based on science?

      Fifteen percent of doctors and nurses have substance abuse disorders, and your profession kills and injures hundreds of thousands of Americans every year and does next to nothing to improve patient safety, largely due to uncaring, misanthropic attitudes like yours. But you’re worried about a smoker getting asthma treatment? Try taking a look around you. You’re the bloody last people who ought to be judging anybody, when you close your eyes to all the abuses, fraud and cruelty that goes on this system.

      Get off your high horse.

      • http://twitter.com/ButDocIHatePink Ann Silberman

        Well said, I could not agree with you more.  When i was so sick, dying really, I heard these cruel people outside my door having conversations like this, completely dehumanizing those of us behind the curtains.  I was in for c-diff, but was referred to as the “metastatic in room four” like I was not a person, just a disease.  The nasty comments I heard, the assumptions that one man made about people he did not know would make you sick.  Yet, these (hopefully few) biased people want to decide the fates of others simply because they think because they went to med school that they are better than those around them.  

        • Payne Hertz

           You an tell a lot about a culture or institution by what is allowed to be said within it. Open expressions of racism are now taboo in American culture, and any leading figure who used the “n” word would certainly find himself castigated for doing so. You can assume from this fact that being openly racist is unacceptable among civilized people, though that kind of language probably wouldn’t stir any debate at a KKK meeting.

          Similarly, we can tell a lot about medical culture by what it’s members feel comfortable saying in public, or just among themselves. When doctors feel comfortable coming on to forums which are widely read by their peers and saying things as horrible as this, it’s evidence they expect few of their peers are going to object to it. If more doctors objected to it, then fewer doctors would feel so comfortable spewing the kind of bilge they do on their blogs and more doctors would challenge them when they did. Notice how quickly the backtracking began here when challenged by a few patients. The effect would be greater if the condemnation was from other doctors.

          But views like this are rarely challenged by other doctors in forums like this, even with the safety of anonymity they afford. Generally, they will instead attack anyone who dares to question the “truth” of the articles in question, with only a small minority expressing any dissent if at all.

          The silence here speaks volumes.

          • karen3

            Well said.  And the really concerning thing is that as far as I am concerned, alot of the derogatory comments are really closet bigotry using terms that are socially acceptable instead of terms that are forbidden.  Do you have any doubt that generally when the medical profession is complaining about fat diabetics who aren’t compliant, who eat fried chicken etc, they aren’t talking about an African American in code.  When they are talking about smokers, they don’t have in their head a poor person. It’s just the same old bigotry, but cleaned up for public consumption. If the docs showed up in white sheets, it would be obvious. The white coats, not so much. And I am as Caucasian and right of center as a person could be.

          • Payne Hertz

             There is no doubt that racial code words and concepts are often used in these diatribes. Sometimes they are subtle, like the guy in the ambulance with a liter of Mountain Dew or the proverbial “drug-seeker” eating Cheetohs in the the waiting rooms (stereotypical “black” junk foods). Other times they are blatant, like the alleged drug seeker who shows up with his “entourage” or “homies” or his “familia.”

            At the same time, this kind of animus in the real world is definitely not confined to blacks and Hispanics. Having been involved in chronic pain support groups for two decades, the overwhelming number of people I have met and talked to have been white middle class, and every single one of these people reports being treated abusively and dismissively by the medical profession, even those who mange to get their pain treated promptly which is the exception rather than the rule.

            I am white but also cursed with an obviously Irish name, and my medical records reflect my ethnic heritage and the stereotypes that surround it with mutlitple doctors at the VA accusing me of having a “history of alcohol abuse” and “severe drinking problem” which is news to me since I don’t drink alcohol at all and don’t recall having a drinking problem or stating that I did. Then again I lack the omniscience of some.

          • karen3

            My mom, who was a former corporate executive and lived in a tony location nowhere in the mid-Atlantic somehow always ended up living in “West Virginia” in her patient history.  And apparently they thought patients from “West Virginia” don’t need to be fed and she had a heart attack due to starvation.  Yeah, yeehaw, with my doctorate I would never catch that slam or what happened as a result of it.  

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

       Actually, plenty of non-smokers get Non-small cell lung cancer too like BAC. I find it funny how you are a nurse yet you singled out small cell lung cancer in non-smokers instead of non-small cell lung cancer.

    • Sapphire Storm

      No! Why not explore the problems of these people who are addicted to health endangering behaviors. You act as if it is a problem to YOU; yet you are being paid, very well I imagine, to *deal* with such problems. But if you really want to understand and actually deal with the problems you would be open to understanding addiction and studies geared toward such people. Hard to understand the ignorance coming from such a well educated segment of society.

      • pattiern

        You are confusing objectivity with ignorance, madam.  You also seem to think that we have never seen or treated addiction, AND that all of those killing themselves the long and expensive way ARE addicted.  Most are not, they simply have zero motivation to change anything in their lives…..why should they?  Someone else will always “patch them up”, until the day that is medically impossible.

        And, unless you have never been employed, you are also paying for this foolishness out of the wages YOU get for whatever it is you do.

      • 7yearend

         I’m glad you kept fighting their one-sided patients vs doctors out look on humanity! I can’t begin to understand what is wrong with so many of these people? You have basically said that addiction is a symptom of the disease and they don’t seem to understand, yet most of them work as medical professionals?  I think everyone has missed what your saying because they don’t want to acknowledge that addiction itself is a disease, just like pain can be a disease in it’s self…then their patients aren’t really to blame and that would mean that humanity as a whole seems to be suffering largely from a deep seeded depression, an emptiness that can’t be filled and addiction is a side effect from trying to self treat that consuming sadness that has washed over humanity like a tsunami. We seem to be lost in our failure…it’s so sad to read some of these posts from the medical professionals patients like myself who are extremely sick and suffering depend on to care for us and give us hope have completely given-up on their patients before we are even seen! I know that there are a lot of doctors,ect. who actually enjoy watching their patients suffer, enjoy watching as their patient begs and pleads for treatment while on their knees crying… I know because as a pain patient I’ve been there. And I know if I can’t find a caring, competent understanding doctor to treat me soon I will have to end my life, but I always hoped that there were more doctors out there that did care than those who were lost and gone! It just goes to show you how screwed-up humanity is! When I read these posts I realize that I’m better off dead than putting my life in the hands of some of you pathetic bastards!!

  • karen3

    If we are going to be so unforgiving about mistakes, how about life imprisonment for medical errors?

    • John Henry

       Mistakes, or willfully-wasteful self-destructive behavior and woeful dereliction?  Not the same, you know.

      • karen3

        Your “mistake” as a doctor might be what I consider to be “woeful dereliction.”  It all depends on where you sit.  

        • MuddyWaterz

          From reading some of your posts, I can only conclude that you must have been harmed in some way by the medical establishment. Much animosity from you there is.

          • Payne Hertz

             Standard boilerplate apologist response. Repeat ad nauseum for effect. That’s all you can conclude? Funny, but I can imagine hundreds of other reasons for having issues with malpractice though certainly being the victim of it helps. That the only motivation for dissent against this system doctors like you can imagine is some hate fantasy coaxed up by disgruntled patients is evidence of just how far removed you are from giving a damn about your patients or the truth.

      • Sapphire Storm

        Why is it not the same? Is it the University Degree? It IS the same. Being a SNOB has no place in Public Health. Get over yourself.

  • Worth It

    Angienadia, health care professionals like yourself are around drugs everyday, it’s tempting, and very easy to become addicted. I would hope by now you’d know how much drug and alcohol addiction there is in the health care field. The US places restrictions on a state license and considers someone an “impaired professional” until they overcome addiction and go through rehabilitation.

    Would you feel it’s a waste of resources for a physician or nurse to go through rehabilitation because they could relapse (like you said “crash and burn a bigger flame, taking much needed resources with them”)? It would be easier for a physician or nurse give up their license and find a different career away from patients, drugs, and pressure. Instead of giving up on addicted professionals the state gives people a chance to get help and use resources for rehabilitation. Your attendings, your friends, your patents, and you could suffer from addiction and a medical license will not make you superior and you could lose it.

    It could be said that children get priority for blood transfusions because they are younger and will live longer. Does that mean a mother should bleed to death during a c-section or does the mother have a right to resources like a transfusion so she can live and raise her baby? What about the right of a mother that smokes, eats fatty food, or does other things to damage her health? Should a child be given blood instead of an injured physician? The examples I could give about this subject are endless and it’s a slippery slope.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is our fault. This entire thread is our fault. When we start telling physicians that they need to pay attention to resources and populations, and practice lean medicine, and be aware of costs to society, we should keep in mind that here and there some eager young docs will be tempted to take the next logical step. So here you go: this is the next logical step and it will be taken. And sooner or later, the next step after this will also be taken. 

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

       AGAIN – there is ZERO evidence that prevention or healthy lifestyle save money, in fact there are studies to the contrary. It’s just that for the majority of people their preconceived notions and perceptions matter more than facts.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Seems we are just catching up with our friends across the pond…

    I wonder what comes after smoking and obesity… maybe drinking or promiscuity? Brave new world…

  • Will

    angienadia–it is a sliding scale of activities and conditions, and it impossible to rationally put your finger at one point on that slope and say, “enuf is enuf”. I share your frustration, having seen same for 30 years, but for your own sake, you need to focus on what you can do for that pt in front of you. Any other approach will take you to a person that you don’t want to be. 

  • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

    I don’t see a way around it.  To maintain our humanity and ethical standards we have to treat these people if they are asking for help.  Calling 911, like this woman did when she became SOB was asking for help even if she still was wanting to smoke her cigarettes.  Makes you wonder, ‘why do these people even call for help if they are not going to follow our advice??!!’  Yet, they must have been terrified enough in that moment to call.  Anyway, it certainly is frustrating and wasteful on resources, yes, but what option do we have?  Say, ‘no, you reached your 911 limits or hospitalizations for the same reason so we refuse to take you’?  As human beings we can’t do that.

    Anyway, I think to help limit wasted resources we need to reward good behavior instead of punishing bad.  For example, like a lot of insurances do now if someone doesn’t smoke make their insurance premium lower.  Do the same thing for someone within their normal weight range or even diabetics that keep their HbgA1C within normal ranges, people that keep a preventive follow up schedule (ie annual pap smears, or checkups/bloodwork, etc)…reward them with lower healthcare insurance premiums.  Insurances could even give these compliant pts a monetary reward at the end of the year.

    • Sapphire Storm

      You seem to have a kind yet removed perspective. To say: These people…indicates that you see yourself as separate from them. There is no position of rewarding good behavior over bad; that is paternalistic and doomed to failure; but also is so antithetical to health care. In health care we must embrace the difficult to understand cases and to also see what these cases bring up in ourselves. It scares me, the opinions of people against: those people. One day it could be you!

      • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

        Sapphire, there are different groups in pt population and you have your head in the sand if you don’t acknowledge that.  There are non-compliant pts and yes, that is exactly what I meant when I said ‘these people’ as opposed to compliant pts. 

        You need to go back to psychology class if you don’t think rewarding good behavior doesn’t work. I’m not saying its the end all be all but we have to do something to try to reach ‘these people’ to try and change their behavior.  They contribute to the sky rocketing health care costs by their non-compliance.  Wake up.

    • Dorothygreen

      The only way to deal with this issue is real prevention and a a societal effort to curb addictive behaviors.  The woman addicted to tobacco has, at least for the last 20 years, paid some of the cost of her addiction upfront.  Also, she has had warnings on packages and access to other interventions.   Now she represents whatever number of the 20% who still smoke tobacco and develops COPD or cancer.  Alcohol is also taxed, perhaps not enough – there are warnings – perhaps not enough.  There is AA.   I do not know what the percentage of our population are alcoholics – if the percentage has decreased.    And then there is excess sugar, excess processed fat, excess animal consumption, excess sodium – available 24/7, cheap and ever so tasty.  The hard core addiction here is reflected in an obesity rate of of 1/3, another 1/3 overweight and many who remain normal weight but do so on high sugar consumption.   It is difficult to feel empathy.

      Smokers have to pay a higher price for insurnace.  In Switzerland. the premium is set and then reduced if one does not smoke or does not make claims.   This concept is easy enough to develop in the US as described here by Lydia.  They have a 9% obesity rate and are becoming concerned and addressing the far fewer problems in health care they have relative to the US.  

      But it is not enough.  We MUST reform our eating culture.  The current voluntary Food Revolution is not enough.  We must make it part of health care reform.  The farm bill is a start.  It needs to be delayed so Big Ag does not get what it wants to maintain the status quo.  We need small farmers, more local subsidzied vegetables – cheap and tasty – grown in the USA.  Big food knows they must change but they are doing it so slowly and deceptively that there is little to no impact.   We need to tax processed sugars, processed fat , and sodium. RISK messages on the packages.  Stop the ads on TV.   Theefforts (and laws if necessary like taxation) need to be as pervasive as fast food signs.  

      ICUs were meant to save the lives of the sickest people.  Unfortuately, more than half of the sickest people are addicts.  But the good news is, it is preventable.  

  • Minimalist_Fiend

    It won’t be the docs that decide when enough is enough for people who wish to harm themselves and hog resources better directed at others, it will be the bureaucrats.  Guess what? I long to be one those bureaucrats to implement appropriate, reasoned, well informed policies to no longer guarantee a cure to people who harm themselves, only health care.

    • Sapphire Storm

      Hog resources? Maybe it is not well understood why people cling to addictions and further their health complications. Does that mean that we as a society act in ignorant ways towards them? That only those who are well adjusted to life deserve medical care? I think you need to re-evaluate your opinons and understand that health care goes beyond simple medical diagnosis and moves into the car eof the whleperson and that person’s needs.

      • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

         Sapphire, are you in the medical field?  Whatever their intention or reason, do you not see people misusing resources d/t their non compliance?

      • Minimalist_Fiend

        Your attitude will continue to bankrupt our health system, and when that happens? No one gets care!

    • Fred Ickenham


  • paulzi

    If people want to commit suicide, let them be. Or, at best, you offer those people life again only once. That’s it. Otherwise you kill yourself of depression. Whom you don’t let die, doesn’t let you to live. As cruel but real as it is.

    • Sapphire Storm

      You are an ass.

      • paulzi

        This “a” as you wrote is going to work now. In a hospital. As a doctor. This “a” is 51 and have seen quite a few things up to know. I promiss a more detailed answer after I come. And, as I use to, in an English without expressions that you so gracefully used at my address. Have a non stressful day! 

      • paulzi

        As promissed, here I am again. You must be very young on the field of very optimistic about what we, doctors shoud do. The issue is an everlasting debate and, to some extent, I agree with many people who posted here, that we have no right of decision of whom to try to save an whom not. I have personally seen, and not once, people with amputated limbs due to periferal vascular disease as a result of heavy smoking, who told the medical team repeatedly: “I prefer to die smoking instead of quitting”. That person come to the ER in a coma. What are we supposed to do? You know it is a futile struggle, an useless expense of preciuos resources to…a dead end. I suggest you read something on satisfaction at work, burnout and alike. These are things we didn’t learn in the medical school and we were even not aware of some years before. I also suggest you read something form Cronin. In the old Greek city of Sparta they killed the newborns with deffects/anomalies. Technically speaking they did an epidemiological social treatment by preventing a certain biological error to perpetrate. At the human level and in nowadays it is debateble: how many genies have not been or are crippeled! In remote and isolated populations, the contact with a killing disease self limits its spread because all that population will be extinct sooner or later. Nature has its own ways of selection. If my memory is good, there have been a famous case where a patient has been saved in the last moment from imminent death by having heart coronary surgery. He was a heavy smoker. He was warned: if you do not quit smoking you are in danger of repeating the heart attack and die. No other surgery will be offered to you. He  quit smoking for a while, than started again. And…arrived to the hospital. No surgery was re-done. And the patient died. Who was to blame? And why blame at all. I hope I was able to let you see and understand that the coin has two faces. It is very easy to throw on someone else invectives and injuries, but it is also desirable to understand that the medical treatment is usually a two parts dance: the doctor and the patient. You cannot make a couple if the patent just refuses to listen to the music. And then…you let go. There are many other patients that would benefit sincerely from your decision. As cruel as it may be or seem to be. “Dura lex sed lex” (find the translation from Latin). 

  • Molly_Rn

    As someone who has clinical depression and
    must take medication for it, I am a bit troubled about this post and the
    responses. I can’t help but wonder if these people are self-medicating and in
    doing so slowly killing themselves. They are all using legal drugs that are
    incredibly harmful, yet our society says they are legal. Coming off a bad
    asthma attack, I can’t help but think that when the smoker couldn’t breathe she
    called 911 as suffocation is a god awful way to die. I am not
    convinced that we really understand the pathology that makes people self-destruct
    like this. I am just a soft hearted nurse who can’t judge someone else for fear
    that I will be found wanting and judged. The blogs lately have been more and
    more cruel hearted and lest compassionate. Maybe it’s me, but life is difficult
    and we all didn’t get dealt good cards. I too have been frustrated with
    patients that vomit blood from esophageal varicies every New Years, always
    vowing to never drink again, or the COPDers who puff their buts from their
    stomas, but there but by the grace of god go I and I cannot be uncaring. I
    cannot imagine being addicted to something like cigarettes or booze that are
    killing me and make huge profits for legal companies in the US. Cigarettes are
    nicotine delivery systems, no different than a syringe for heroine. That is
    what frustrates and disgusts me. Profit made on others suffering.

  • HealthCareProf

    I am not do sure I would call what you do “heroic”. You were trained to do a job. You have modern medicine and technology at your disposal. You have patients in need of help. Do your job and stop judging others.

  • Sapphire Storm

    Wow~ such cynicism. Very disheartening to see in a doctor. Very shortsighted. We have to, as a community (both medical, psychological and other) to address the reasons people turn to substances to alleviate mental or physical pain. Even mental illnesses contribute to these problems.
    Truly I am astonished at the cold-hearted and uninformed attitude in this article. Someone with diabetes, especially at the age of 20 (when did this person get the disease) might be depressed. Someone who smokes regardless of health consequences might have life experiences that cause her to be unable to give up her addiction. On and on. Until we treat people’s mental issues along with their physical ones as one cohesive unit, these sad situations will occur over and over.
    I have son newly diagnosed with Diabetes type 1. No, he is not fat (lest you judge), it is inherited. He goes through bouts of depression and his father does not quit understand and wants to push him into his future while the poor boy deals with the changes in his every day present. Personally I am sick of the judgments of doctors and health care professionals such as you. I know they have contributed to the death of my sister.
    Yes she had Hep C; Yes, she drank. But she was also very depressed and had no transportation. So beyond the judgments there could have been compassion; and in that compassion there could have been a solution and a life lived.
    To be honest, I feel a lot of anger around what you post. I feel it is very negative and uninformed and more “old school” rather than new and innovative and I am sorry to see that. Very sorry.

    • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

       Sapphire, I’m sorry about your son being diagnosed with diabetes.

      You have to understand from the health care professionals perspective what we see EVERY SINGLE DAY WE WORK.  It’s extremely frustrating.  What do you suggest?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I would suggest that you find another line of work. Frustration, which is plentiful in many professions, does not entitle workers to proceed to killing customers.

        • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

           OF COURSE we cannot kill customers and where did I even suggest that????

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Deciding when a patient has received “enough” resources based on his/her “worthiness”, as evaluated by you, after which no more care should be provided, is equal to deciding that this unworthy person should go home and die. It is a death sentence delivered by a panel of one.

            The medical profession exists, and is well rewarded, because people decided to reward care and compassion and curative efforts. There is enormous trust placed in clinicians and this is at the base of the elevated social and financial status bestowed on the profession.

            Nowhere did the people empower physicians to decide on who is worthy of care and who is not, or who brought this on themselves and who did not. If you folks attempt to assume such divine responsibilities, and presume to act as both judge and executioner, I would venture a guess that society will be withdrawing all trust and support from this new form of the medical profession.

            Your job is to be your patient advocate, no matter how filthy, how unresponsive, how exasperating, how morally reprehensible he or she is. If you cannot do that in good faith for each and single patient, you should not be a clinician.

          • ellejean

            Where is the line drawn with regards to finite resources? I’ve witnessed what it’s like for one ICU patient to absolutely exhaust the blood bank, so that when we received a trauma the patient had to be flown to the next closest hospital (63 miles away).

            I truly don’t know what the answer is, but seeing patients repeatedly choose to “undo” the efforts that have been made to save them, is like spitting on the rest of society. It’s equivalent to throwing away food in front of a starving person. Our system can’t afford to be wasteful of resources when there are others desparetely needing them.

          • Fred Ickenham

            It must be nice to be up on that high horse, while not in any way providing a cost-effective solution in days of escalating costs like these, and remaining harshly judgmental anyway. YOU don’t stay up all night caring for these self-induced train wrecks. This doctor provides excellent care, the cost of which will prevent needed care elsewhere for those innocents who did not cause their diseases.

  • Hyun Nam

     Hello, I wrote a blog on this article and the crucial topics that surround it. I would be very grateful if people could read it and put their inputs on it. I am a premed student and after reading this article I became very confused about the topic of Should a line be drawn for those patients who continue to damage themselves even after treatment. My uncle has Parkinsons disease and at times he refuses to take his medication and does that mean in the eyes of doctors he is seen as a “waste” of resources.

    Thank you and here is the link,


  • http://profile.yahoo.com/JZ3QJKN73LU2XH4A6ODOVL3IYI Jan

    I’m not a lawyer, but wouldn’t it be considered some degree of manslaughter for physician to deny critical treatment to a person under their care?  As far as I know, there are no “three strikes” rules concerning patient “noncompliance”, nor should there be. Doctors orders are advisory, carrying no legal weight, unless accompanied by a judicial order barring a person from use of legal substances. The Hippocratic Oath should provide the answer to this one – no need to look to the law for guidance.

    I think referring a person to a treatment facility in the case of an alcoholic or drug user, and counseling in the case of a smoker is appropriate.  

    Ask your patients to file a DNR order so you both know the limits of intervention.

    If a physician would like to have a limit on treatment, you’ll need to go to your state legislature and lobby for a law that would allow you to determine who is deserving of care. You would likely get support from the private prison industry. Society would likely consider you mad.

    • 7yearend

       As far as refusing treatment goes, many doctors and nurses already do that! They get away with it all the time! I am a chronic intractable pain patient… I can barely walk, I’m often bed-bound and house-bound, I have type 1 diabetes because of this horrible illness and I often think about how and when I will take my life all because I require opioids to treat my constant nightmare of agonizing, incurable, severely UNDER-TREATED Intractable pain. I am dismissed constantly by all doctors and all of society! Pain patients in this country are tortured by under-treatment or even non-treatment and either forced to the streets to find relief for their pain or forced into suicide! It is hopeless for us to maintain our health when the very people who are supposed to be taking care of us immediately dismiss us as drug-seekers or addicts and throw us out of the hospitals! The pain that consumes every inch of my mangled, crippled body is worse than anything and I MEAN ANYTHING you could ever perceive, never-mind actually living with it for 7 years like I have! I am constantly being tortured, belittled, ridiculed, lied to, broken-down, beaten down and tossed out like trash by people that took an oath to do no harm…what a horrible joke…do no harm…It is especially wonderful when my pain flares making it impossible for me to control my rising blood sugar and blood pressure and I go into DKA; diabetic ketoacidosis, throwing-up till I can hardly breath. Then my wife calls the ambulance even though she knows whats going to happen but she tries anyway! Maybe this time they will at least treat the DKA…but it won’t matter much if they don’t control my pain levels…..or maybe they will take one look at me and say “oh this guy, he is a frequent flyer… bring him out to the waiting room!”  and I pass out, then they take me seriously, after I almost die again! So to the MD that wrote the article about wanting to refuse treatment and would like to play god in a different crueler way, sorry but you are too late! Your self-righteous peers have been torturing and killing people like me for a long time now and it’s just swept under the rug, maybe you could just take out all your frustrations on us weak, scared, broken-down, cripples who are so completely devastated by indescribable amounts of pain that we won’t fight back against the almighty doctors, sound good?! Is that what you want to do! You think your frustrated with your patients? You can’t even begin to imagine how angery I AM with doctors like YOU! 

    • Fred Ickenham

      This massively expensive problem of self induced disease, plus the laws requiring futile treatment of it, is THE PROBLEM of the whole ACO model, and will doom it, absent legal changes.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

     Don’t pay attention to this thread, Hyun and don’t let it confuse you. The people writing here have lost their way. It may have something to do with our harsh political discourse nowadays, or it may just be that these folks are confusing medicine with social engineering or medieval priesthood. Either way, medicine in one form or another has existed since the dawn of civilization. There are plenty of examples to guide your way, other than this unfortunate one here.

    • Hyun Nam

       Thank you for your reply. I just had a problem with the wording in this article as it may have offended many people with sick family members.

      • http://www.facebook.com/profile.php?id=100000360772707 Lydia Yatras

         In my mind, this article wasn’t directed to people with sick family members like your uncle.  He was talking about situations where pts CLEARLY are doing the same bad behavior over and over again…leading them to hospital admissions over and over again….for a personal choice.  Your uncle didnt make a personal choice to get Parkinsons.  Some people do make a personal choice to get COPD though b/c they refuse to quick smoking despite much ignored advice from the docs.

        • Hyun Nam

          You make a good point there… but he made a personal choice to avoid medication which leads to the worsening of his condition and then more visits to the doctor. Which may lead to the frustration that Dr. Angienadia was talking about. So in my mind i think my uncle could relate to this article a little bit.

          Also, like i have said before, i just had a problem with how Dr. Angienadia expressed her concerns for these patients, who may have family members themselves that value these “heroic” measures. By “how” i mean the wording of a few sentences – and although the solution to this problem is elusive to many – maybe she could have pitched in a paragraph explaining what she believes would be the solution to this problem instead of ending off with “should have stopped sooner…”

          • meyati

            Part of the problem is your region. My husband had an aunt that went through multiple knee and hip replacements, and 2 pacemakers. She asked me if it would be suicide if she refused treatment because of the associated pain. I talked to her about do not resusitate orders, etc. I asked her if she felt that God was calling her, did she feel that only medical science was keeping her from the next step. She went and talked to her PCP, and he was relieved that she wanted to pass. He was scared to talk to her because of the extreme religious beliefs in that area. She passed in the ER a few months later. The family said that I murdered her.

            While the family doctor can delicately talk about this, it’s difficult to talk about philosphy in the ER-good way to be sued too.
            There’s such a difference between an abuser of the body, and a person that becomes ill or has an accident. My opinion is that counseling seldom helps, as the patient must want to stop the destructive actions. As humans, we can’t help but have times where we wonder about the waste of time and resources on these people. My daughter had a VA patient that suffered from mini-strokes, and his cognitive assesment skills were declining during the hospitalization. She went out one day, and he and spouse were on the patio, puffing away. My daughter felt disgust, until her brother and father reminded her that the only way a recruit can take a break is to smoke-while the non-smokers had to keep doing push ups. All anybody can do is to offer resources.
            This is the price of freedom-that angienadia can discuss this and feel saddened and disgusted about the problem, and the patient has the freedom to live their life as they want.
            I want to remind everyone that what’s dangerous to one person is a way of life for others. I much prefer country doctors to city doctors. So where do we draw the line? Which activities are dangerous? Baths, because you might slip? Staying in bed and developing those problems? So doctors should treat patients no matter what.

  • 1990CC

    Thank you for your honesty.

  • anothermd

    I feel your pain, angienadia. It’s very frustrating to feel like your hard work may not lead to long lasting benefit for your patients. I have also poured blood products into a cirrhotic with bleeding varices, knowing it was futile, but compelled to do so nevertheless. And I think it is natural to develop some cynicism. Especially since our approach requires us to distance ourselves to maintain some level of objectivity in our decisions.

    I understand why you wonder aloud if cutting some people off wouldn’t be better. But I also imagine that after you wrote this you went back to work and continued to deliver the same quality of care to all your patients. Because that’s what we do. Patients and families will never ask less of us, and frequently ask for more.

    We get it from all sides: patients with unreasonable demands, insurance systems who will not help our patients get adequate care, delusional family members, hospitals that chant “get ‘em out, get ‘em out,” outpatient clinics with crushing minutiae preventing efficiency, and bizarre and tragic social situations in which there really is no solution.

    Through it all, there are some gems. I try to focus on those. Try not to think of the fact that your frequent fliers will continue to bounce back. Fight the good fight and let it go. When it gets to be too much, pretend you just got a page and leave the room. Breathe deep.

  • 7yearend

      As far as refusing treatment goes, many doctors and nurses already do
    that! They get away with it all the time! I am a chronic intractable
    pain patient… I can barely walk, I’m often bed-bound and house-bound, I
    have type 1 diabetes because of this horrible illness and I often think
    about how and when I will take my life all because I require opioids to
    treat my constant nightmare of agonizing, incurable, severely
    UNDER-TREATED Intractable pain. I am dismissed constantly by all doctors
    and all of society! Pain patients in this country are tortured by
    under-treatment or even non-treatment and either forced to the streets
    to find relief for their pain or forced into suicide! It is hopeless for
    us to maintain our health when the very people who are supposed to be
    taking care of us immediately dismiss us as drug-seekers or addicts and
    throw us out of the hospitals! The pain that consumes every inch of my
    mangled, crippled body is worse than anything and I MEAN ANYTHING you
    could ever perceive, never-mind actually living with it for 7 years like
    I have! I am constantly being tortured, belittled, ridiculed, lied to,
    broken-down, beaten down and tossed out like trash by people that took
    an oath to do no harm…what a horrible joke…do no harm…It is
    especially wonderful when my pain flares making it impossible for me to
    control my rising blood sugar and blood pressure and I go into DKA;
    diabetic ketoacidosis, throwing-up till I can hardly breath. Then my
    wife calls the ambulance even though she knows whats going to happen but
    she tries anyway! Maybe this time they will at least treat the
    DKA…but it won’t matter much if they don’t control my pain
    levels…..or maybe they will take one look at me and say “oh this guy,
    he is a frequent flyer… bring him out to the waiting room!”  and I pass out, then they take me seriously, after I almost die again! So to the MD that wrote the article
    about wanting to refuse treatment and would like to play god in a
    different crueler way, sorry but you are too late! Your self-righteous
    peers have been torturing and killing people like me for a long time now
    and it’s just swept under the rug, maybe you could just take out all your frustrations on
    us weak, scared, broken-down, cripples who are so completely devastated
    by indescribable amounts of pain that we won’t fight back against the
    almighty doctors, sound good?! Is that what you want to do! You think
    your frustrated with your patients? You can’t even begin to imagine how
    angery I AM with doctors like YOU! 

  • Fred Ickenham

    This harsh emotional judgmentalism damages the LEFT more than any other factor. It’s typical of the fringes of both parties.

  • Fred Ickenham

    Oh sure, a “Conservative”

  • Fred Ickenham

    Ha!!  What a powerful argument you make! YOU pay for her care, pending her genius breakthrough.

  • Fred Ickenham

    WRONG!!  So many studies show that preventable disease costs at least 40% of healthcare costs. HELLO?

  • DD92

    Prolongation of death. . . Many times, as Angienadia described, that is the result of aggressive, well intentioned ICU management. All of us are mortal and will face death. The time to consider what level of “critical care” we want, is when we are well. Health care providers ideally, should have this discussion with their healthy patients. And if that regularly occurred, maybe some of the horrific scenarios encountered in ICUs all over the US could be avoided. Along with the monetary considerations associated with prolongation of death is the physical suffering of the dying patient and the mental anguish of family members.

  • meyati

    Somewhere, nobody is thinking of the patient that’s been waiting for hours or even days, which does happen in Albuquerque.  I had a friend that would be called in for assesment/physical check-in, and another ambulance showed up with an alcoholic or another smoker had a heart attack, it took him over 20 hours, and he was pre-med-atypical shingles, so his classmates misdiagnosed.  I think that we need a different triage system to give health providers and other patients a break. Perhaps in the larger ERs they could have a “fast check out” like at the grocery stores, where a certified PA handles what seems to be the less urgent patients with ailments other than alcohol-the child with hives or light case of flu, expedite the patient with dark urine, the flu, shingles, whatever. It would reduce contamination from the infectious patients that can breathe and aren’t bleeding out. Many places now have pediatric urgent care. Things like this should be expanded for a 24/7 medical care. Hospitals and ERs are shutting down. Patients walk out and refuse to pay. The medical staff could be rotated to help reduce burn out-the patients would be happier. If a system doesn’t want to do that- they could have a back-up that they call in when the moon is full or whatever. Just because a patient doesn’t seem to be really sick doesn’t mean they aren’t-that drunk can have their first diabetic episode or be dehydrated from a med. I took Previcid for a week- my tongue was stuck to the roof of my mouth– They ended up using pediatric needles when they drew blood, because my veins were blowing, and then started an IV on “the old drunk” as they had been calling me. One young doctor put me last because I was an old drunk. It didn’t help that my abusive husband told them that. Fortunately they got a specialist in alcoholism-and he quickly realised what was going on. 

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