Now that is a good question, and no one knows the answer for sure. But there is substantial anecdotal evidence that doctors are more likely than others to have their Advance Directive filled out and are more likely to die as they would wish. According to the California Healthcare Foundation, 70% of Californians would prefer to die at home but only 32% do so. Physicians tend to die more often at home and we subject our bodies to fewer painful and pointless interventions at the end of life.
The reason seems clear. We doctors tend to have a pretty realistic attitude about what is helpful and what is harmful when approaching life’s end. When weighing the pros and cons of various options, we usually make reasonable and realistic choices for ourselves. If we have a terminal illness and a possible treatment will make us sick as a dog with little prospect for extending life in a meaningful way, most doctors would forego that option.
The fact that doctors die differently than their patients is starting to garner more public attention, and that is probably a good thing. A 2011 blog article by Ken Murray, MD, family medicine professor at USC, surfaced this issue for all to see and the posting has received over 600 responses. The blog article and the comments can be found at: http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/. The article itself is interesting and the responses are fascinating.
While it may be clear why doctors choose to die the way they do, the issue of why others die differently is more complex. The general public does not have the same level of understanding of the dying process as do physicians. They rely on us to explain things when issues arise. Yet only 7% of Californians report that their physician has talked with them about end-of-life options. There are many reasons why these discussions are not happening in the doctor’s office. Time is short. Other clinical issues need attention during the office visit. Discussions about end of life care are time-consuming. They can be uncomfortable.
So there is no blame being doled out here. It is not easy. But we have to figure out ways to do better. We can offer patients hand-outs with relevant information. We can train our office staff to help with these discussions so we don’t have to do it all ourselves. We can have Advance Directives pre-printed and ready to hand out to our patients.
When I’m trying to make a difficult point, I often turn to the car repair business and I think it’s time to do so now. I recently took my sturdy 13-year-old car to the shop for a routine 105,000 mile check-up – kind of like an annual physical. The mechanic called me later that day saying that after running a lot of tests, it was clear part of the front end was going out and needed to be replaced. It would cost me about $1,200. Well, maybe it was clear to him, but I had no clue what he was talking about. I asked him what it meant that the front end was going out, what the options were, and what would happen if I did not have the work done. He answered me as best he could, struggling to dumb down his answers so that someone like me, who knows zip about cars, could understand the issues and options. I inquired about whether my car seemed otherwise in good enough health that I should spend that kind of money on major surgery. He said the car seemed otherwise in good shape. Fixing the front end would likely give the car more time. But, he said, a decision to proceed depended on my values (yes, he used that word) and what I wanted out of the car, since it was pretty old and had a lot of miles on it, not to mention the body had a lot of dings and scratches. I thanked him for his expertise, thought about it for an hour, then called him back and told him to go ahead and fix the front end.
Now, I’ll be the first to say that being an auto mechanic is not the same as being a doctor, and a car is not a human body. But there are a few parallels. My mechanic’s advice helped me decide what do to with my aging car. As physicians, we can play a similar role with our aging patients. Of course, the stakes are very much higher. And this is why the work is very much more important.
Richard Fleming, MD