Источник: The Wall Street Journal

Why doctors, dying, refuse resuscitation

MD from Southern California, Ken Murray, explained why many doctors wear pendants with the inscription "Do not pump out," and why they prefer to die from cancer at home.

Leave quietly

- Many years ago, Charlie, a respected orthopedic doctor and my mentor, found a lump in his stomach. He was given a diagnostic operation. Pancreatic cancer has been confirmed.

Diagnosis was conducted by one of the best surgeons in the country. He offered Charlie a treatment and an operation that allowed him to triple his life with such a diagnosis, although the quality of life would be low.

Charlie did not care about this offer. He discharged from the hospital the next day, closed his medical practice and never again went to the hospital. Instead, he devoted all his remaining time to the family. His state of health was good, as far as possible with the diagnosis of cancer. Charlie was not treated with chemotherapy, nor with radiation. A few months later he died at home.

This topic is rarely discussed, but doctors also die. And they do not die like other people. It’s amazing how rare doctors seek medical help when it comes to an end. Doctors are struggling with death when it comes to their patients, but are very calm about their own death. They know exactly what will happen. They know what options they have. They can afford any kind of treatment. But they go quietly.

Naturally, doctors do not want to die. They want to live. But they know enough about modern medicine to understand the boundaries of opportunities. They also know enough about death to understand what people are most afraid of - death in torment and in solitude. Doctors talk about this with their families. Doctors want to be sure that when their time comes, no one will heroically save them from death, breaking ribs in an attempt to revive with an indirect massage of the heart (which is exactly what happens when the massage is done correctly).

Almost all the medical workers at least once witnessed a "vain treatment" when there was no likelihood that the deadly patient would be better off from the latest medical advances. But the patient is ripped open the stomach, pokes the tubes into it, connects to the apparatus and is poisoned with medicines. This is what happens in the intensive care unit and costs tens of thousands of dollars per day. For this money, people buy suffering, which we will not cause even terrorists.

Doctors do not want to die. They want to live. But they know enough about modern medicine to understand the limits of opportunities.

I lost count of how many times my colleagues told me something like this: "Promise me that if you see me in this state, you will not do anything." They say this quite seriously. Some doctors wear pendants with the inscription "Do not pump out", so that doctors do not do an indirect heart massage for them. I even saw one person who made himself such a tattoo.

To treat people, causing them suffering, is painful. Doctors are taught not to show their feelings, but between themselves they discuss what they are experiencing. "How can people torture their loved ones like that?" - a question that haunts many doctors. I suspect that the forced causing of suffering to patients at the request of families is one of the reasons for the high percentage of alcoholism and depression among health workers compared to other professions. For me personally, this was one of the reasons why I have not been practicing in the hospital for the last ten years.

Doctor, do everything

What happened? Why do doctors prescribe a treatment that they would never have prescribed to themselves? The answer, simple or not - patients, doctors and the system of medicine in general.

The patient is ripped open the stomach, puffs into his tubes and is poisoned with medicines. This is what happens in the intensive care unit and costs tens of thousands of dollars per day. For this money, people buy suffering. Imagine this situation: a man lost consciousness, and he was brought to the hospital by ambulance. No one foresaw this scenario, so it was not agreed in advance what to do in such a case. This situation is typical. Relatives are frightened, shocked and confused in a variety of treatment options. Head is spinning.

When doctors ask "Do you want us to" do everything "?" - the family says "yes." And hell begins. Sometimes the family actually wants to "do everything", but most of the time the family just wants everything to be done within reasonable limits. The problem is that people often do not know what is reasonable and what is not. Confused and grieving, they may not ask or hear what the doctor says. But doctors who are told to "do everything" will do everything without reasoning, it is reasonable or not.

Such situations happen very often. The matter is sometimes aggravated by completely unrealistic expectations about the "might" of doctors. Many people think that artificial heart massage is a safe method of resuscitation, although most people still die or survive with deep disabilities (if the brain is affected).

I took hundreds of patients who were brought to my hospital after resuscitation with artificial heart massage. Only one of them, a healthy man with a healthy heart, left the hospital for his two. If the patient is seriously ill, old, he has a fatal diagnosis, there is almost no probability of a good resuscitation outcome, and the likelihood of suffering is almost 100%. Lack of knowledge and unrealistic expectations lead to poor decisions about treatment.

Of course, not only the relatives of patients are to blame for this situation. Doctors themselves make useless treatment possible. The problem is that even doctors who hate vain treatment are forced to satisfy the desires of patients and their relatives.

Forced suffering to patients at the request of families is one of the causes of high rates of alcoholism and depression among health workers compared to other professions.

Imagine: relatives brought an elderly person with an unfavorable prognosis to the hospital, crying and hysterical. They first see a doctor who will treat their loved one. For them, he is a mysterious stranger. In such conditions it is extremely difficult to establish a trusting relationship. And if the doctor begins to discuss the issue of resuscitation, people tend to suspect him of unwillingness to mess around with a complicated case, save money or time, especially if the doctor does not advise continuing resuscitation.

Not all doctors are able to talk with patients in understandable language. Someone is very categorical, someone is snobbish. But all doctors face similar problems. When I needed to explain to the relatives of the patient about the different treatment options before death, I told them as soon as possible about only those possibilities that were reasonable in the circumstances.

If relatives offered unrealistic options, I simply delivered all the negative consequences of such treatment to them in plain language. If the family still insisted on treatment, which I considered meaningless and harmful, I suggested that they be transferred to the care of another doctor or another hospital. Doctors refuse not from treatment, and from retreatment

Was it necessary for me to be more persistent in persuading my relatives not to treat mortally sick patients? Some of the cases when I refused to treat the patient and passed them on to other doctors are still haunting me.

One of my favorite patients was a lawyer from a famous political clan. She had a severe form of diabetes and terrible blood circulation. On the leg - a painful wound. I tried to do everything to avoid hospitalization and surgery, knowing how dangerous hospitals and surgical interventions are for her.

She nevertheless went to another doctor, whom I did not know. That doctor almost did not know the history of this woman’s illness, so he decided to operate it - to shunt the trough vessels on both legs. The operation did not help restore blood flow, and postoperative wounds did not heal. Gangrene went on the soles of the feet, and both legs were amputated to the woman. Two weeks later she died in a famous hospital where she was treated.

Both doctors and patients are often victims of a system that encourages excessive treatment. Doctors in some cases get paid for every procedure they do, so they do all that is possible, regardless of whether the procedure will help, or will do harm - just for the purpose of earning. Much more often, however, doctors are afraid that the patient’s family will sue, so they do everything the family asks, without expressing their opinions to the patient’s relatives so that there are no problems.

Both doctors and patients are often victims of a system that encourages excessive treatment. Doctors sometimes get paid for every procedure they do, so they do everything they can, regardless of whether the procedure will help, or will harm the system.

It can devour a patient, even if he has prepared in advance and signed the necessary papers, where he expressed his preferences for treatment before death. One of my patients, Jack, has been sick for many years and has experienced 15 serious surgeries. He was 78. After all the ups and downs, Jack absolutely unambiguously told me that he never, under any circumstances, wants to be on the IVL.

And one day Jack had a stroke. He was taken to the hospital unconscious. Wife was not around. Doctors did everything possible to pump it out, and transferred to the intensive care unit, where they connected to the ventilator. Jack was afraid of this most of all in life! When I got to the hospital, I discussed Jack’s wishes with the staff and his wife. Based on documents compiled with the participation of Jack and signed by him, I was able to disconnect it from life support equipment. Then I just sat down and sat with him. Two hours later he died.

Despite the fact that Jack made all the necessary documents, he still did not die the way he wanted. The system intervened. Moreover, as I found out later, one of the nurses was accusing me of disabling Jack from the apparatus, and therefore committed a murder. But since Jack pre-recorded all his wishes, I did not have anything.

People who are cared for by the hospice live longer than people with the same diseases that are treated in the hospital

And yet the threat of police investigation horrifies any doctor. It would have been easier for me to leave Jack in the hospital on equipment, which clearly contradicted his wish. I would even earn more money, and the Medicare insurance company would receive an additional $ 500,000. Not surprisingly, doctors tend to re-treat.

But doctors do not cure themselves. They see the consequences of re-treatment on a daily basis. Almost every person can find a way to peacefully die at home. We have many opportunities to alleviate the pain. Hospice care helps fatally ill people spend the last days of their life comfortable and dignified, rather than suffering from vain treatment.

It’s amazing that people who are cared for by the hospice live longer than people with the same illnesses that are treated in the hospital. I was pleasantly surprised when I heard on the radio that the famous journalist Tom Vicker "died peacefully at home surrounded by family." Such cases, thank God, are occurring more often.

Several years ago my cousin Torch (torch - torch, torch, Torch was born at home with the light of a burner) had a cramp. As it turned out, he had lung cancer with metastases to the brain. I talked to different doctors and we learned that with aggressive treatment, which meant three or five visits to the hospital for chemotherapy, he would live for about four months. Torch decided not to be treated, moved to live with me and only took pills from the brain edema.

The next eight months we lived for fun, just like in childhood. For the first time in my life I went to Disneyland. We sat at home, watched sports programs and ate what I was cooking. Torch even recovered at home grub. He was not tormented by pain, and the disposition of the spirit was militant. Once he did not wake up. For three days he slept in a coma, and then died.

Torch was not a doctor, but he knew that he wanted to live, not to exist. Do not we all want this? As for me personally, my doctor is notified of my wishes. I’ll go quietly into the night. Like my mentor, Charlie. Like my cousin Torch. As my colleagues are doctors.

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