Doctors are practicing irrational medicine at the end of life

I just took care of a precious little lady, Ms. King (not her real name), who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practice at life’s end.

Ms. King was a case in point: She was a 92-year-old nursing home patient on hospice for metastatic breast cancer. Ms King had been transferred to the ER for a sudden drop in blood sugar, presumably due to her oral diabetes medication. Her appetite had apparently been trailing off, as is common at the end of life, and her medication appeared to have become “too strong.” Her glucose level had been corrected by EMS during her trip from the nursing home to the Hospital, so when I came into see Ms King she was at her ‘baseline.’

I opened the door to bed 24 and a grinning little white-haired lady peered at me from over her sheet. “Hi,” she said greeting me first.

“Hi, Ms King,” I smiled back at her and picked up her hand.

She reached over with her free hand to pat me on my forearm, “You sure are a cute little doctor,” she said smiling.

I couldn’t hold back a little laughter. “Well, you sure are a cute patient too,” I smiled and winked at her.

She winked back at me.

“Wow, this is the most pleasant 90-year-old I have cared for in a while,” I thought to myself.

As we chatted it became clear to me that she had some mild dementia but had no pain or complaints at the time. She just said, “I think I had a ‘spell’” ( a “southernism” for some type of unusual and undefined episode of feeling ill or fainting); and “I’m not hungry” when I offered her food.

Leaving her room still smiling after our pleasant exchange, I went back to look at her medical record from the nursing home and two things immediately struck me:

1. She was on 20 medications, only about half of which seemed needed or appropriate to me. For instance, if someone is expected to die from cancer in the next 6 months (which is why she was on hospice care), why should that person take a cholesterol pill every day?

  • Is it going to change her outcome? No.
  • Will it add to her comfort? No.
  • Could it possibly cause unnecessary harm? Yes.
  • So, why is she on this medication? No rational reason that I can think of, other than mere habit on the part of the doctor.
    • Doctor habit: See an abnormal lab value ( i.e. elevated cholesterol) = give a pill to correct it. While this is a fine default among the rest of the population, this type of unconscious medical practice at the end of life is contributing to wasteful drain of precious and scarce Medicare and Medicaid dollars. We cows (doctors), need to depart from these types of paths. If the usual pill, practice or procedure does not have any benefit for the dying person, if the typical treatment doesn’t create comfort, or may actually harm this person, then DON’T DO IT! Get off this path!

2. She was on hospice care but her order sheet read, “Full Code.” I can never figure this one out. If you or your family member enters hospice care this means that you generally accept that your time on this earth is limited, specifically to less than 6 months or so. Thus, it is irrational to ask for chest compressions or shocks or artificial life support measures when your expected end comes. Right? Didn’t you sign up for hospice because you were wishing for a peaceful, natural death? Well, not everyone agrees with me, so I called Ms. King’s power of attorney to clarify this point, it was her son, Mr. King.

Mr King was a pleasant man who said that he was unable to come to the hospital because he himself had suffered a stroke. After I explained the full code vs Do Not Resuscitate/Allow Natural Death pathway, he said, “Oh No! she never wanted all of that life support stuff. Both of us want what you said, ‘ a natural death.’”

I was curious that he so readily had me change this order, so I asked, “Now, has any doctor or nurse ever had this conversation with you before?”

“Nobody said anything that I could understand.” Was his reply, “but I know what you are talking about.”

I rolled my eyes up and shook my head silently while holding the phone.

How many times do little ladies like Ms. King, who are clearly at the end of life, have “Full Code” orders written or carried out only because:

i) no doctor has every talked to the family, or

ii) the family simply didn’t understand the jargon of the doctor.

  • How many times do little ladies like Ms King end up being “coded” with rib crushing chest compression and transported back to the ER, when all they ever wanted was a peaceful end?
  • How many times are little ladies like Ms King “resuscitated” only to lie in the ICU on a breathing machine for 2 days before their hearts give out for the final time?
  • Would CPR change Ms King’s outcome of death from metastatic cancer? No.
  • Would a successful resuscitation ( i.e.restarting her heart despite a crushed rib cage) add to her quality of life? No
  • Would artificial life support add to her comfort? No.
  • Would seeing her dead body, with tubes sticking out of every orifice, give her family a sense of peaceful closure about her death? No.
  • Yet we as a nation pay for these types of outcomes every day, because this scenario happens every day. I contend that this is largely the fault of us doctors, we are failing at having the right conversations in the right way. We are too busy just doing things the way we have always done them, practicing in our default pathways and patterns … and it’s not working!

We have got to start practicing conscious, rational and caring medicine at the end of life. We doctors must ask ourselves, “What medications really matter for this patient?” We must be having conversations that the patients and families can actually understand. We must be talking about how the “high tech” pathway at the end of life may actually create or prolong unnecessary suffering. We must instead focus on communicating that the “high touch,” comfort-focused pathway is most likely to give final peace to all parties- patients and families alike.

Becoming less like cows, and awakening ourselves to these changes in practice pathways will not only rescue our patients and families from needless medical interventions and suffering at the end of life, it might just help save the life of the Medicare and Medicaid systems as well … and that’s something to “Moo” about.

Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.

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  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Wow, what an amazingly thought-provoking article. I think that this is something that the family members of the patients need to read as well. Thank you for sharing this.

    • http://twitter.com/Oktodie OK to Die

      Kristy,
      Thanks and I agree, families and patients need to be hearing and reading this type of commentary from us doctors much more often. It’s more realistic than what they see on TV!
      Monica Williams-Murphy, MD
      http://www.oktodie.com

  • leslie fay

    AMEN! As a respiratory therapist of almost 40 years I can tell you that this kind of thing happens all the time. Poor little people are also brought in from nursing homes who really ought to be in hospice. It is so pathetic. The system is broken and the cows (doctors) really need to get “mooooving” and fix it.

  • Molly_Rn

    Seriously thinking of having DNR tattooed
    on my chest, maybe it should say if you bring me back as a vegetable, my family
    will sue the pants off you.

  • drjoekosterich

    Great article. we need to be far more questioning of what we do. In particular we need to consider the circumstances of the individual. I had a patient aged 89 with a cholesterol of 4.8mmol/l started on a statin whilst in hospital!

  • http://www.facebook.com/people/Rusty-Wilson/1522904359 Rusty Wilson

    I am a life member, since 1993 when it was The Hemlock Society, of Compassion & Choices. My wife died peacefully at home under hospice and my care from stomach cancer in 2004. I now live, retired since 1995, happily alone doing as I please. Although I have a very good doctor it is stories such as this that make me have a quick final exit plan; my worse nightmare is not being able to execute it because I was hospitalized from off the street and no longer in charge, or capable of being in charge, of my own affairs. My daughter knows my wishes as my Health Care Proxy but nevertheless I don’t trust our medicine for profit setup with its Hypocritical Oath.

    Are they cows or do those doctors also suffer from terminal greed, today’s plague. Thank you Dr. Williams-Murphy for being a real doctor involved in health care rather than wealth care.

    Molly_Rn has me also thinking of having DNR tattooed on my chest. Maybe I should also find an ambulance chaser lawyer as my Health Care Proxy.

  • James Sinclair

    I appreciate the fact that this is a common place situation with many lessons of the absurdity to which medicine has gone in treating disease not patients. I am sure there may be some situation where a 90 year old should be a full code on a statin and oral hypoglycemics but certainly not with metastatic cancer. The family MD, Oncologist, hospice MD, RN, Social Worker and Chaplain all failed Mrs King. At least you got a compliment from a wise woman before she died!

  • LBENT

    My aunt who had metastatic lung cancer with brain mets was given chemotherapy the week she died. I think that these “life-saving/life-prolonging” treatments are for the purposes of either making money and/or the inability of the physician to say there is nothing left to do. The patient is going to die. We also see this in pediatrics where a neurologically devastated child is kept alive on a ventilator for decades and the family will never consent to enough is enough. Sad.

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