
How doctors choose to die (2012) - arfliw
http://www.theguardian.com/society/2012/feb/08/how-doctors-choose-die
======
sago
This is anecdotal evidence from a small (2) sample. But not all doctors die
without treatment at home. Some (many?) are aware of the drugs they need to
hasten their demise in a way that minimises their suffering. One doctor I
discussed this with said that assisted suicide, in a very limited and measured
way, isn't uncommon, if you know what to look for.

As someone with a degenerative incurable condition, I'd like the option of
being able to make informed decisions about the end of my life, beyond just
refusing treatment. Because spending years dying of starvation (as MS
campaigner Debbie Purdy recently did, because she was unable to cope with her
symptoms, and there was no other legal recourse to help her die), doesn't fill
me with excitement.

We have an insane attitude to death in our culture at the moment. We seem to
want to find any way to avoid the fact that being alive has a 100% mortality
rate. I think our collective attitude needs to change. And the more articles
like this the better.

~~~
themartorana
It's really hard to change perceptions about death when it requires
considering one's own mortality. It is in this only that I understand the
desperate quest for religion. The idea of going dark forever is terrifying to
me, and considering I'm pretty much an atheist, I don't have much hope of
anything else. When people ask me if I'm religious, I usually tell them I'm
hopeful that I'm proven wrong.

I know we all die. I know our lives on a cosmic scale are infinitesimal. But
even I - as rational as I am, am extremely scared of facing that reality head
on.

So convincing the entire nation/world to do so... Well, good luck with that.

~~~
sago
It doesn't frighten me. It won't go dark forever. Just as there was no 13.5bn
years of darkness before I was born. There will be no qualia of time.

I think attitudes are changing. The campaign to be able to determine how and
when we die is shaping up to be a significant battle for a fundamental civil
right. I think we'll win it. Whether it is soon enough for my wife to avoid
threat of prosecution if she is with me when I choose to act, I don't know. I
suspect not.

~~~
the_gipsy
> It doesn't frighten me.

I don't think that's entirely true - it's just that all functioning members of
society displace or ignore their fear of death with some method.
[http://en.wikipedia.org/wiki/Death_anxiety_%28psychology%29](http://en.wikipedia.org/wiki/Death_anxiety_%28psychology%29)

~~~
Ntrails
Why in gods name would I be frightened of oblivion? Dying is terrifying,
because it comes with implications of suffering. No longer existing is simply
enthralling. I will simply be gone. A just reward for making it through a
lifetime imo.

~~~
the_gipsy
I can't tell you why the thought of ceasing to exist would be frightening. It
simply is to me, and I believe to most people. And most people, including me,
ignore it and focus on the joys of life. There are of course different degrees
of this displacement, some people may still acknowledge the idea but others
might completely convince themselves that there is nothing to be scared of -
or maybe there really _is_ a way to enjoy a finite life span.

Mind you that this a very intimate and subjective topic, and I am not saying
that you are fooling yourself, but from someone who is indeed scared of death
(the end of life), it does seem plausible.

~~~
sago
_I am not saying that you are fooling yourself, but_

The mirror image is that we aren't fooling ourselves, we've just been able to
rise above our heavy inculturation to such fear. An inculturation that you're
still stuck in. That seems plausible too.

That's meant in good humour btw, my point is really that speculation that
other people disagree because they are in denial, or ignorant, is pretty
tempting, but usually not very helpful to discussion.

~~~
the_gipsy
I don't mean to say that "other people are ignorant". I myself ignore and
displace this constantly... until at some moments I am reminded. I actually
didn't intend to sound condescending, I should have made clear that I actually
ignore death myself.

Regarding inculturation: I believe it is actually right the other way round!
That a child when first encountering the thought of death and its implication,
is naturally terrified, and that _our society /culture_ provides means of
coping with this fear.

------
ColinWright
And the bowl of petunias said: Oh no, not again.

For those interested in the collective wisdom of the HN community, here are
some previous discussions:

[https://news.ycombinator.com/item?id=3313570](https://news.ycombinator.com/item?id=3313570)
: 1206 days ago | 177 comments

[https://news.ycombinator.com/item?id=4865742](https://news.ycombinator.com/item?id=4865742)
: 841 days ago | no comments

[https://news.ycombinator.com/item?id=5017104](https://news.ycombinator.com/item?id=5017104)
: 807 days ago | no comments

[https://news.ycombinator.com/item?id=5104430](https://news.ycombinator.com/item?id=5104430)
: 790 days ago | 94 comments

[https://news.ycombinator.com/item?id=6040804](https://news.ycombinator.com/item?id=6040804)
: 618 days ago | 1 comment

[https://news.ycombinator.com/item?id=6767385](https://news.ycombinator.com/item?id=6767385)
: 489 days ago | no comments

[https://news.ycombinator.com/item?id=7446014](https://news.ycombinator.com/item?id=7446014)
: 368 days ago | 2 comments

~~~
arfliw
While that certainly is an intimidating set of links you have there, only two
of those have any discussion -- one over two years ago, the other nearly four
years ago.

~~~
ColinWright
Indeed - has anything changed?

If not, then those discussions are still relevant, and there would be value in
skimming them rather than simply repeating all the points again.

If so, then it would be of value to see what has changed, possibly by reading
the previous discussions. Perhaps the mood of the audience has changed,
perhaps the general opinions of the HN community have shifted.

Either way, being aware of the past is of value.

    
    
        Those who cannot remember the past
        are condemned to repeat it.
    
            -- George Santayana
    

_EDIT:_ People often misunderstand these back-links. They are not intended to
scold people for submitting things that have been submitted before. On the
contrary, I believe some things should re-surface from time to time, bringing
them back either for the informing of the newer community members, or for re-
evaluation in case things have moved on and should be re-considered. My main
concern and motivation is that previous contributions should not be wasted.

~~~
arfliw
The two with discussion are certainly relevant. The others were not. To me,
they served only to give the false impression that this has been discussed a
lot more than it actually has.

> They are not intended to scold people for submitting things that have been
> submitted before

So I guess that explains why you began with 'oh no, not again'

~~~
ColinWright

        > The two with discussion are certainly relevant.
        > The others were not. To me, they served only to
        > give the false impression that this has been
        > discussed a lot more than it actually has.
    

That's why I said how many comment there were - to give the data that there
were lots of submissions, not all of which had generated discussions.

    
    
        > So I guess that explains why you
        > began with 'oh no, not again'
    

Yeah, OK, point taken. I guess I've just been around too long and read too
much stuff. I went away for a while and have only just started to read again,
but I guess I'm still too jaundiced.

I'll go away again. Sorry.

Do you want me to delete the comment? I think there's still time.

~~~
arfliw
I didn't realize you quoted the number of replies, I thought HN did that
automatically.

>I'll go away again

haha i never said to go away. play it like it feels. i'm biased since you were
responding to my submission.

------
jrapdx3
When facing terminal illness, doctors probably differ little from comparably
educated subsets of the population. I don't know of studies specific to
physicians, but my guess is quality of life is a priority that shapes
decisions about treatment for life-threatening conditions.

After decades in practice, doctors have faced death of patients many times.
It's not an experience one ever really gets used to. As a result, doctors tend
to be realists about illness and its likely outcome.

It's no surprise that doctors might choose "death with dignity". Oregon, where
I live, was the first state in the US to pass a law legalizing physician
assisted suicide. The _Death with Dignity Act_ went into effect in 1997.
Studies have consistently shown that the leading motivations among those
requesting lethal prescriptions are the desire to maintain independence and
minimize reduction of QOL.

Comprehensive data/stats related to DWDA can be downloaded--the most recent
report (2014) is here--
[http://public.health.oregon.gov/ProviderPartnerResources/Eva...](http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf)

Additional info is available--
[http://public.health.oregon.gov/ProviderPartnerResources/Eva...](http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/index.aspx)

------
mytochar
I'm a little frustrated with this article, but not for the reasons in the
article. The doctors were angry at their patients' family members for putting
them through the suffering; but, ... that form of suffering is just where
medicine is right now.

Medicine is evolving, and growing; and, it's that desire to keep living and to
keep those around you living, and to improve their well-being that has, in
part, grown our medical abilities to the point they are now.

It feels like some of those improvements that, right now only provide a '15%
chance of survival, and include pain', will be the stepping stones for 20, 30,
80 or 90% chance of survival, with varying levels of pain, including 0.

The article seemed to suggest that the doctors didn't approve of those
intermediate steps, but ... those are the steps medicine takes, aren't they?

I dunno. I respected the rest of the article. That part of it bothered me.

~~~
dragontamer
It isn't the doctor's job to improve medicine, it is a researcher's job.

Doctors can only prescribe to you the 15% chance of survival, knowing that
there's no greater benefit to medicine. They're too busy seeing patients to
improve medicine.

~~~
mytochar
I'm not sure this is accurate, especially in the case of cancers. Doctors were
part of the studies with at least one person I know.

------
shazad
Atul Gawande, who's written extensively on end of life issues, had an
excellent one hour Frontline special that covered the same topic. I highly
recommend watching it if you're interested at all in how terminal illness and
dying are handled in the United States today:
[http://www.pbs.org/wgbh/pages/frontline/being-
mortal/](http://www.pbs.org/wgbh/pages/frontline/being-mortal/)

~~~
quickpost
His book on the same topic is absolutely enlightening and surprisingly
enjoyable to read, despite the sobering topics.

Being Mortal.

[http://www.amazon.com/Being-Mortal-Medicine-What-
Matters/dp/...](http://www.amazon.com/Being-Mortal-Medicine-What-
Matters/dp/0805095152/)

------
mct
A few years ago, I heard an NPR interview with a doctor who's friend was
terminally ill. Rather than opt for treatment, the friend spent his remaining
time living with his doctor friend. He died a few months later. The doctor
said that this is how she wanted to die, too. I've tried a number of times to
find the story, but I haven't been able to. Does it ring a bell for anyone?
I'd love to listen to it again.

Thanks!

~~~
berberous
That does not specifically ring a bell, but Radio Lab did a piece on this
topic once. Perhaps it's in there:

[http://www.radiolab.org/story/262588-bitter-
end/](http://www.radiolab.org/story/262588-bitter-end/)

------
hippiefahrzeug
This reminded me of an article I've read a long time ago which had a really
strong impact on me. I've just found it by googling a couple of words that
were still in my head after all these years.

Here it is (probably not where I originally read it):
[http://www.nbcnews.com/id/21643646/ns/health-
behavior/t/what...](http://www.nbcnews.com/id/21643646/ns/health-
behavior/t/what-we-learn-dying/#.VRJtuDTF-l0)

~~~
rckrd
Fantastic and relevant read.

This was surprisingly well written for an NBC or Men's Health article for
those who are skeptical.

------
jimt67
I thought this was thoughtful and well written but all I see is
anecdote...there is no data presented that MDs choose different options than
non-MD patients.

~~~
FireBeyond
Adding to the anecdote, I'm a paramedic who has also opted for 'no heroic
measures'. Even with CPR survival rates in this county being amongst the
highest in the country.

~~~
gr3yh47
Is breaking of the ribs really a requirement of CPR done correctly? My
understanding was that it is possible for ribs to break but by no means a
requirement of correct CPR as the article implies.

~~~
FireBeyond
It depends. Depending on the age of the person and the fragility of the bones.
It's not a "requirement" in any sense, more "if it's not a risk, you're not
going deep enough" \- typical standards call for 1/3 to 1/2 the chest depth.

As often as that - it's much more (almost guaranteed) that you'll tear the
cartilage between the ribs at the front.

------
sandworm
It isn't just how they die. Similar articles could be written on "How doctors
loose weight", "How doctors pick their doctors" or "What do doctors do when
their kids are sick". Insider knowledge and the education to effectively
employ that knowledge always has advantages.

I do take issue with the concept that these docs are dieing "without
treatment". They get treatment. They are diagnosed (a big deal) and have ready
access to a host of pain management drugs. Having a full understanding of your
condition, along with the knowledge that any pain can and will be managed very
quickly, is a massive stress reduction. That's a form of treatment imho.

------
screature2
Can't speak for other people, but the fascination for me is a combination of
decisions that are difficult and universal and then watching to see how
subject matter experts (who view this stuff on a day to day basis) choose for
themselves.

I think this invariably results in deeply moving meditations on mortality and
dignity from both sides of the table (care provider and patient). Or maybe I'm
just suffering a recency bias from this: [http://med.stanford.edu/news/all-
news/2015/03/stanford-neuro...](http://med.stanford.edu/news/all-
news/2015/03/stanford-neurosurgeon-writer-paul-kalanithi-dies-at-37.html)

~~~
hkmurakami
There's also a factor of compliance and regulation that affects what doctors
are able to say to their patients.

------
mattlutze
I had a conversation about this with a friend yesterday.

What I would like to understand, is what the difference is between one
incurable terminal condition and the next is, and why we're culturally stuck
on trying to divide things up into "approved" and "not-approved" categories.

Death happens for everyone. Most everyone, if they make it to very old age,
will have degenerated physically and mentally from where they once were. I
wonder, if our sympathies are telling us to consider whether a person with X
condition should be allowed to end their life, whether that same thought
process shouldn't consider all end-of-life conditions to be equal, given their
shared terminality and expectation of degeneration.

Or, on the flip side, should we think terminality and expectation of
degeneration in these cases is not enough, whether it is appropriate to accept
it in this subset of cases.

------
marincounty
There's one thing they left out of the article. Yes, we are all going to get
sick, and eventually die. Doctors--know the expected survival rates. Doctors
do seem to end up with the right medications to really make those last days
comfortable, or take the right amout and overdose properly?

Now, their patients, especially the poor, stereotyped, etc. are sent home, and
when a doctor feels like they need Hospice, they give their approval.

I had a poor friend die. It was obvious he only had a few months left, but the
doctor wouldn't o.k. Hospice? We went to two clinics, and a pain clinic and
neither would give him the medications (Opioids and Benzodiazepines) he
needed. One pain clinic(noted one of the better ones--in San Francisco)
offered to cut some nerves?(I still don't know what these Blow Hards wanted to
cut.)

Why didn't he get the right medications; well in the states we assume everyone
is going to abuse drugs. It's just getting worse. Doctors are not taking away
pain.

O.K., but once you have Hospice, everything is fine these fine? Doctors are
trained in Pallitive care--if you get lucky. My experience watching my father
die of liver cancer was a week of Hell. Hs last words to me before he went
onto one of his last comas was "Son--when will this end?" Yea--no shit!

The nurse finally came around. She then let my sister manipulate his
medications which made his discomfort even worse.(my sister thought he should
spend more time with his grand kids, and she wanted him to give her more
things?) There I said it. Yea, she's a piece of work.

I know this. When I am given that diagnosis of death. I used to think I would
go to the bad part of town and buy smack, crack, whatnot, but as I've gotten
older and I don't have the fight in me like I did in my 30's; I will probally
just suffer through the agony of death like my father endured? Or, I might do
what Robin Williams felt he had to do?

Robin's wife said she was glad he picked up his ipad when he walked by her.
She said, Robin hadn't watched tv, nor went on the Internet for the last six
months.

Robin was found in his stepson's bedroom with a belt around his neck. A towel
was wrapped around the belt. I'm assuming to make the suicide more
comfortable? Crude knife marks on his wrists--from a pocket knife. An ipad was
found near the body with websites open to the the various side effects of the
drugs he was given. I don't know all the drugs he was given, but they found a
bottles of Seroquil? and a drug used to help with the neurological disorder he
had.

Why did I repeat this story. Because this is how we are forced to die in the
United States. I don't know why Robin committed suicide. He sounded like he
was suffering for a long time, on many levels? I don't know if the
prescription drugs he was taking made things worse? Either way, he shouldn't
have had to die like this. I'll pass this along too. Don't think suicide is
easy. I knew a guy who tried to blow his head off with a shot gun. He blew his
frontal cortex off, and spent the next 30 years paralized in a rest home. He
died of a lung infection. I didn't know him personally. I worked for the
Cororners office at the time, and picked up hs body.

Enough, I feel sick from even writing about this gruesome stuff, but nothing
changes. Doctors should treat the pain of their patients, and the government
shoud not harass them.

And we need a "right to die with dignity" law like Oregon passed. They passed
it a few years ago, and very few decided to use the kit. Most decided to go
naturally, but it must be reassuring knowing you have an alternative? I yacked
on, but it's something I think about often.

------
cup
This has been posted a number of times in different iterations on HN. I'm
curious why the user group here has such a fascination with medical doctors.

~~~
sho_hn
Engineers have a peculiar relationship with doctors. When they have need of
one, and the doctor decides on a treatment plan for them, they think about the
complexity of the problem space the doctor had to navigate to reach that
decision. They wish the doctor would chart the parameter space for them, so
they can agree or disagree with the choice in an informed manner, and have
more of a clue about the competence of the doctor. This is usually not what
happens, not to their satisfaction anyway, and it's deeply unsettling having
to trust rather than know when it comes to something that appears so much like
engineering on the surface.

An alternative title for this article might be "what doctors really think",
and thus strikes to the heart of this issue.

~~~
shiven
Or, as a (former) doctor, I love telling my engineer friends:

Intuition can't be formalized.

Part of the reason simply being the "system level" thinking that has to be
developed, practiced and honed by any doctor worth his/her salt. And when you
think of it, even with our current understanding of the human organism and the
phenomenon called life, we are primarily working using 'heuristics', barely
glimpsing the ultra-complex jigsaw that makes everything tick. Someday, when
the _ken_ of this knowledge is complete, we may be able to formalize the
logic, albeit, the 'computer' it runs on, may well be as complex as our own
brains!

~~~
im2w1l
Want to bet? I'll bet that in 20 years we will have programs that can diagnose
a patient and explain how it came to its conclusions.

