Tuesday, March 13, 2012

Doctors are Not Magicians

The nurse, who was in her late 40s noticed the surprise that registered on my face when she said that she would be getting a tattoo for her 50th birthday. I assumed that most people of her social stature would be comfortable enough in their own skin by that age to avoid using that skin as an ink canvas.

The tattoo, she explained, would be placed directly above her left breast and would consist of three large block letters: DNR. From her name tag I could see that these were not her initials, so I asked about the significance of those letters. She said rather matter-of-factly, "Do not resuscitate." Having spent her career as an emergency room nurse and having participated in many resuscitations, she had no desire to be the "victim" of such an effort.

I thought about this nurse as I read Dr. Ken Murray's article titled Why Doctors Die Differently. Most of those that perform heroic medicine, it turns out, opt out of being on the receiving end of that type of treatment. Dr. Murray explains:
"Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right)."
Perhaps those of us that don't work in medicine are so steeped in unrealistic myths that we overestimate the power of our medical system to bring us back to a decent quality of life. Dr. Murray notes that medical outcomes depicted in entertainment media differ dramatically from reality.

When it comes to CPR as shown on TV, for example, 75% of cases were successful and 67% of patients went home afterward. In real life only 8% of CPR patients survive at least a month, and only 3% of these survivors can go on to lead a normal life.

A beloved uncle was diagnosed with the early stages of lung cancer some time ago. He opted for the chemo and radiation therapies that had a good chance of killing the cancer. He survived, recovered, and was found to be cancer free for a number of months.

But the cancer recently returned with a vengeance. Over a relatively short period of time he went from having no detectable cancer to having it spread throughout his body. Instead of opting for heroic treatment that might extend his life a few months, he chose to be as comfortable as possible and to spend as much time with his loved ones as he could during his remaining days.

There is something to be said in favor of living one's final days and passing gracefully.

Dr. Murray advocates executing an advanced health care directive "specifying what steps should and should not be taken to save [your life] should [you] become incapacitated." You should also inform anyone that might end up in a decision making role in such a situation of your wishes. This gives them a framework for resisting heroic efforts that might have more to do with improving the practitioner's financial, legal, or self esteem situation than enhancing the patient's quality of life.

The limits of medical reality are also behind Dick Teresi's article on why he refuses to sign up for organ donation. It turns out that you pretty much give up all your rights once you sign up, should you ever become a "beating-heart cadaver."

Teresi details the simple tests used to certify that someone is brain dead. "Most people" he writes, "are surprised to learn that many people who are declared brain dead are never actually tested for higher-brain activity."

In the interest of saving precious time, some perverse incentives have been built into the transplant system that can cause practitioners to inadequately consider the prospective donor's best interests.

Teresi recounts a doctor's tale of how a donor had his organs removed even after he began spontaneously breathing on his own. He explains how supposedly brain dead people respond negatively to pain they are not supposed to be able to feel during the removal process.

Refusing to sign up for organ donation doesn't mean that your survivors can't decide that your organs can be donated. But it can give them bargaining power that they will lack if you do sign up. Teresi suggests, for example, that your family members could require that practitioners test you for higher brain activity and that they give you adequate anesthesia.

Our modern medical system is built on the shoulders of the mystical healing guilds of ancient cultures. Great efforts have been made to maintain the public perception of the medical profession as having nearly magical or supernatural powers. Those that work in the system know better.

When it comes to the practice of medicine, members of the general public will be better served by the system if they gain and maintain a better understanding of reality. Realistic expectations will likely lead to better outcomes.

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