Doctors uniquely equipped to help others prepare for one of life’s biggest decisions
A recent New York Times article entitled ‘How Doctors Die: Showing Others the Way’ portrays the end of life experience of Dr Elizabeth McKinley, who battled breast cancer for 17 years. When the cancer spread to her liver, lungs, and brain, she made the choice to forego further treatment and enter hospice care.
While Dr McKinley’s husband, also a doctor, accepted and indeed supported her decision, her mother could not, imploring that there must be more they could do. The article described the heartbreaking situation as follows:
Dr McKinley and her husband were looking at her disease as doctors, who know the limits of medicine; her mother was looking at her daughter’s cancer as a mother, clinging to the promise of medicine as limitless.
Dying is as much an emotional journey for doctors as it is for patients – fear, grief, frustration, anger, resentment, loneliness, even acceptance – we experience the spectrum of emotions when we face our own mortality, as do our families.
But when it comes to dying, doctors have distinct advantages over patients. First and foremost, we have the power of knowledge. Even if we have difficulty accepting our condition at an emotional level, we have the knowledge, or access to it, to understand a diagnosis, prognosis, and treatment options. We know what questions to ask, and have access to colleagues and resources that others don’t.
Why then, would any doctor choose the path of least resistance, to forego active treatment, when it comes to their own mortality?
More than most people, doctors have the knowledge and capacity to understand the limits of modern medicine, and when treatments are futile. We are exposed to death more than most – we see people die, how they die, we see the effects of futile care, perhaps even administered it at the pleading of patients’ family members.
In another insightful article on how doctors choose to die, Dr Ken Murray asks the question:
How has it come to this – that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
Patients and family members may have unrealistic expectations of medical treatment, they may mistrust or even fear doctors and the health system. Doctors may administer futile care for a number of reasons – to assuage distressed patients or family members, or out of a fear of reprimand, litigation, or even criminal investigation.
Doctors can play a pivotal role in ensuring patients, and their family members, are prepared to make end of life decisions that respect patients’ wishes and reduce the likelihood of futile care.
Advance Care Planning (ACP) is one means whereby patients can outline their preferences about health and personal care, and preferred health outcomes should they lose decision-making capacity in the future.
While it’s not known how many doctors have their own ACP, it’s likely many have at least reflected on what type of death they would prefer to experience – what care they would like to receive – and to have expressed those views to colleagues and/or family members.
Doctors should strongly encourage patients to do the same.
We can assist patients to prepare for the end of life in numerous ways – engage patients in discussing their values and preferences for end of life care; listen and respond to their questions and concerns; and encourage them to develop an ACP, which may include nominating a Medical Power of Attorney (or similar), or preparing an Advance Directive (or similar), and discuss it with their family and other surrogate decision-makers.
The decision to forego active treatment at the end of life is deeply personal – some patients, including doctors, will continue with treatment longer than others. And while patients will generally not have the same familiarity with death and dying as we do, we can use our own knowledge and experience to ensure they are informed and prepared as best as possible.