Day: January 6, 2012

How Doctors Die

How Doctors Die: It’s Not Like the Rest of Us, But It Should Be by Ken Murray is a very interesting article about how doctors respond to the news that they are terminally ill. It goes into the costs associated with keeping someone alive when their bodies can no longer keep the disease in check – financial, social and suffering costs.

One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

The author recaps a number of stories about doctors who get the news and simply stop working and spend their remaining time doing things they like that make them happy. He feels that for many of them, having seen the suffering caused by futile care for years, the choice to just say “no thanks” is not just easy but the only choice they can make and still do no harm to their patients (in this case themselves).

The article reminded me of doctor Mark Greene in the TV show E.R. He had ended up getting cancer and having a new wife and a young child he fought it and beat it into remission. It did however come back and he made the choice to not fight anymore. It had been hard and he didn’t want to do it again. Dr. Greene spend his dying days in Hawaii with his family and died peaceful in bed.

When I watched the show I remember thinking that it was odd that a doctor would choose not to fight again given that he had been successful the first time. But there was also something that resonated with me that sometimes the distinction that you have a battle to win is simply not true. Even if you are not sick, you will never be new again. Your body has been falling apart since you were born. If you are sick, you will never be cured, even if they cut it out, zap it with radiation and stop the bad cells from dividing. Getting cancer is a one way street and no matter what they do, it can come back. You can fight the toughest battle, but without a new body, the old one has that weakness and the cancer has time on its hands.

There isn’t anything wrong with fighting, there isn’t anything wrong with wanting more time for yourself or your loved ones. There isn’t anything wrong with being grateful for the warning and having the time of your life as it winds down. That’s what a lot of doctors do and I get the feeling it’s what most of my dad’s doctors would do.

Narcissism – A Social Need For The Unenlightened

I wondered for a long time why so many seemingly normal and highly functional people constantly find themselves at the source of all of the bad things that happen in their world yet take responsibility for few of their own actions. It was disturbing until Des told me that believing you’re are a piece of unlovable crap is a sure fire way to ensure that you seek out the social situations to validate your lack of value. Initially it struck me as odd until I saw Donald Trump talking on TV and it hit me that there is a man who doesn’t really care what anyone thinks of him. He’s not narcissistic, he’s confidence because he knows he has a lot of value and this prevents him from needing other people’s approval. He’ll settle for their money and he’s just right for that.

If you are able to consider the inverse – that you are unlovable – you’ll see how seeking out this type of validation is a much bigger a social motivator than KNOWING you are the best. People who know what they bring to the table do not seek out proof of this from others because knowing it is all that is needed. I had an old girlfriend who would talk about things she knew nothing about but when it came time to debate about the things she knew, there was no debate. No need, I didn’t know what I was talking about. She’d correct me and then move on if I continued to disagree. What’s funny is that she would debate endlessly when she was full of crap.

This is one of my favorite topics as I age because I am uncovering more and more people who don’t understand that their motivation to see themselves as the center of the world and the cause of everything is a symptom of a sense of unlove-ability and that it is paying service to something that happened when they were growing-up. More often that not, their narcissism is a result of an incomplete developmental stage and an inaccurate pairing of cause and effect – for example, very attractive people tend to become narcissistic as they age because they were never recognized for their efforts (the things they can control) and tend to receive favor simply for being good looking. Their pathological behavioral patterns will tend to pop out any time they begin to feel overwhelmed by someone they view as better than them (a meaningless distinction) or anytime they feel the withdrawal of approval. They will often say the oddest things that you cannot reconcile in your head because they are not based on fact. To them though, they are based on fact; they are based on the interpretation of the evidence which just happens to see them as unlovable.

We tolerate this from children, movie stars and anyone we want something from because we can’t actually care that much about people who view themselves as unlovable because they tend to act in unlovable ways and alienate those who bring them kindness – they are dishonest, they create drama where it didn’t need to be, they involve others in their and other peoples business, they denigrate others in an attempt to make themselves feel or look better, they tell you who you can and cannot be friends with and they will throw you under the bus as soon as they realize that you are not treating them as unlovable as they act. Narcissism is obvious once you’ve seen it and the people it afflicts are toxic to those unfortunate to have to continue to engage them.

The prognosis is poor for these types of people because they are incapable of seeing their actions has shaping their world – I’ve yet to meet one who later said “I was creating all of my bad luck because I was acting unlovable.” Sadly for them and the people they impact, you tend to hear “look what you made me do” or “that isn’t fair” when you treat them the same way they treat you.

Chances are they are too heavily invested in keeping their delusion going to actually look at the root cause of their actions.