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How Doctors Die (zocalopublicsquare.org)
663 points by thomasgerbe on Dec 5, 2011 | hide | past | web | favorite | 177 comments

So, couple of things. Just had my wife read this (she is a doc) and we chatted about this.

We are in our mid-30s and several years ago she was admitted to the ER and then ICU for 7 days for an obviously life threatening situation. (She has a near blanket NO CODE, FYI). She recovered, but there was at least 48 hours where her odds were "much worse than a coin flip" as on of her colleagues told me.

So people distinguish the different situations, in that situation she and her colleagues (she was treated at her own hospital...given that it was the best hosp in the country) knew about her NO CODE and still treated her. The reason being that medical intervention was near 100% likely to produce a positive outcome and bring her back to a normal quality of life.

However, if given a terminal diagnosis such as in the story, my wife, without hesitation, said she would choose to go without treatment. She went further and wished that this type of article could make its way to the NYT or some other outlet to get normal folks to think about. She, like most doctors, has seen way too many people "try to live" only to saddle their family with huge expenses, not dramatically effect their prognosis and basically make the rest of their lives as painful as possible.

Obviously not a fun conversation to have with your SO, but I for sure know exactly what she wants and how to ask the right questions at the hospital just in case. She also knows what I would want and how to make the right decisions.

Is there a good way to phrase (i.e. "Doctor Speak") for something like "No Code unless a probably positive outcome with intervention"?

Re:saddling their family with huge expenses, this is a fairly unique problem in 1st world healthcare situations, in that it mainly applies to people in the US. In most other developed nations healthcare and bankruptcy do not go hand in hand.

But the money is just as wasted no matter who pays it.

Maybe think of this as one of the burdens that civilization handles for you : One never has to mix the emotional trauma of losing a loved one with the cold facts of how much money they'd save you by dying before tea-time.

This statement is both true, and irrelevant, because who bears the burden is very important for the individual making the decision. What's being weighed is not "are the resources used to keep me alive being efficiently allocated," but rather, "will my spouse and children be irrevocably bankrupted."

What a strange thing to say. It is irrelevant from the myopic point of view of a patient receiving care, at the moment they are receiving the care. It is far from irrelevant as a matter of social policy, because society has to pay the cost even if a particular individual gets off free. Cf. negative externality [http://en.wikipedia.org/wiki/Externality#Negative].

That's true of the actual cost of the service. For the 1000% markup that U.S. hospitals take, it's more arguable.

It's not nearly as much money in other countries. 5 figures on bad odds vs 6 or 7 figures on bad odds. If it's cheap maybe it's worth a shot?

My spouse is also a doctor, and she also went through a life threatening illness. For several days her odds were poor, but full recovery was one of the options. She pulled it through and was lucky. We have had this conversation as well, and her answer is unequivocal: do let me go.

Agree. My wife is a MD also (internal medicine) and the only time I saw her cry was when she received a call in the middle of the night and found out that one of her patients that was dnr/dni (an elderly lady) had exactly that done to her. The staff at the hospital where she was off shift had overlooked the directive.

To everyone considering a "NO CODE" tattoo after reading this story: Don't. If you're really that serious about not wanting to be resuscitated under any circumstances, wear some kind of bracelet or necklace with those words on it, and, just as importantly, a recent date, and contact info for a person who knows your exact wishes. Make sure to update the date regularly.

Medicine changes, and so do your life circumstances. If you're presenting an EMT with a ten-year-old, faded tattoo, you're placing them in an awkward position due to the lack of context. Is this a decision you made ten years ago and got stuck with, or are these your current wishes? They might end up disregarding your wishes just to be safe. A bracelet with a recent date will be much less ambiguous.

And remember, with all medical decisions, you want the ability to change your mind when medical advances are made or your circumstances change. Tattoo removal sucks.

Not to mention that at least where I'm from a tattoo will not and cannot be accepted by EMS personnel as a valid order. Here is the relevant part from our Medical Control treatment protocols on what can be accepted as a valid do not resuscitate order:

"Patient is wearing a do-not-resuscitate identification bracelet which is clearly imprinted wit the words “Do-Not-Resuscitate Order”, name and address of declarant, and the name and telephone number of declarant’s attending physician, if any OR

The EMS provider is provided with a do-not-resuscitate order from the patient. Such an order form shall be in substantially the form outlined in Annex 1 or 2 and shall be dated and signed by all parties."

Anything else and we are required to follow all the regular resuscitation efforts.

How bizarre that they'll accept 'do not resuscitate' on jewellry, but not tattooed across the chest.

"Do we think he really meant it? Nah, he just got the tattoo - if he really meant it, he'd be wearing one of those constantly annoying bracelets"

The bracelet is an official state issued thing for people with terminal diseases. Obtaining one requires a doctor's order.

A tattoo (or any other non-official marking) could be anyone, like a depressed person who is going to attempt suicide.

Something related to this actually happened where I live last week. A 30 year old afghanistan vet wrote "do not resuscitate" on his arm with a sharpie and then shot himself in the chest in a hospital parking lot.

I suspect he meant it, too.

So then why do it in a hospital parking lot? Sounds more like a really excessive cry for help to me.

It depends on the particulars of the story. Perhaps he was hospital-bound. Perhaps he had to visit the hospital so frequently that one day on the way in, he just couldn't handle it anymore.

Perhaps he was thinking of the convenience of the morgue workers.

If I were a doctor, I think I would be more prone to recognize a "NO CODE" bracelet over a tattoo. A tattoo is a decision you made on a single day. Wearing a bracelet is a decision you make every day of your life.

(Of course, you could say that leaving the tattoo in place is a decision you make every day, but it's much easier to remove a bracelet if you change your mind, vs. a tattoo.)

Opt-in/Opt-out, as it were. Considering the consequences, I agree with the reasoning.

What if "NO CODE" is the name of a band?

You're asking someone to make a quick life-or-death decision on ambiguous data when there is a clearly known and socially agreed upon way to express the sentiment.

Having it on an annoying bracelet that is explicitly used to signal medical intent sounds pretty good to me.

So what if "NO CODE" is the name of a band? I'm talking about "Do not resuscitate" - and if you tattoo that on your chest because it's a cool band name, you're an utter fuckwit. 'No Code' is stupid anyway because not everywhere uses that jargon, while 'do not rescuscitate' is clear, plain English.

As for the bracelet, I hate jewellery and anything from my elbows down catches on anything that I'm working on with my hands, and I'm not alone - and unlike the tattoo which is only 'present' at parts of the day, a bracelet is always 'present'. Not to mention that there's all sorts of medical accoutrements that infirm people are supposed to carry with them but don't because they're annoying (prime example being the 'help, I've fallen' pagers).

Of course, "do not resuscitate" across the chest is pretty clear of your intentions when you get it. But I don't think you realize how hard it can be to have that power over someone's life and make that call. I think the point about old tattoos is much more relevant than a band named that; if there are former neo-nazis with ultra racist/symbolic tattoos that regret them, there could be people that just got a "Do Not Resuscitate" tattoo because they thought it was hardcore when they were younger but now regret it. I know this isn't always the case but when you're deciding whether or not to give someone another shot at life, or to let them die, a RECENT bracelet would be more definitive with all the thoughts racing through your head.

Also, if getting a tattoo is less annoying than wearing a bracelet you probably have some of them already and it can become even less clear.

getting a tattoo isn't less annoying than a bracelet, but having a tattoo is much less annoying.

In any case - where is the rash of young people with 'do not rescusitate' tattoos? Everyone I've seen that is supposed to have had one is a greyhair, well out of the young-and-dumb age. And even if you do 'later regret' the tatt and don't want to stump for tatt removal, just tatt a couple of lines through it or tatt something over it.

And then there's the young people who genuinely do not want to be rescusitated - what about them? Stigma enough carrying a medical bracelet amongst the young to begin with. I just don't see this supposed grey area of young people tattooing themselves with a mythical band name.

EDIT: To put it another way, this mythical youth tattooing himself errantly is such a vanishingly tiny fringe minority. Plenty of laws exist allowing for people to freely express themselves to death. The more stringent US states have a maximum blood alcohol content of .08 for drivers, which is higher than the level at which measurable cognitive effects occur on your co-ordination and attention. If we're really concerned about 'free expression' deaths, bring that number right down. There are tons of laws like it. There is no reason not to make it another social norm to say "tattoo 'do not resus' on your chest, and you won't be resuscitated". There's no need to pander to base idiots.

I would prefer we avoid shooting the messengers. Even if there's an argument that EMTs should honor indelible express wishes, we can't have this debate with all of them simultaneously. We are being informed that many of the ones out there today will not, which never would have occurred to me, and knowing that has some value.

Hey "Do Not Resuscitate" could be a good band name too.

This was drilled into our heads in EMT school--without a valid DNR per protocols, we continue CPR. The exact rules vary from county to county and from state to state, but the point is to ensure that the DNR is well and truly valid before denying potentially lifesaving care to a patient (and to legally protect the first responders, who can lose their license/possibly go to jail for recklessly failing to provide appropriate care).

You can read San Francisco's EMS protocol for DNRs--it's more complicated than just saying (or wearing) "NO CODE."

http://www.sfdem.org/Modules/ShowDocument.aspx?documentid=76... (warning: pdf)

Note that the bracelet/necklace frequently has a phone # that the first responders can call to verify the DNR.

I was in Best Buy earlier today and the sales guy who was trying to sell me a TV reminded me a lot of the doctors/residents I was dealing with during a few weeks I spent caring for a family member at Mass General Hospital a couple years ago. I don't think they do it consciously, but doctors try to sell you on their philosophies for healthcare.

But it doesn't matter. You're sitting in a small room with dim lights and someone tells you that you have two choices:

1. You can die a certain death, within months, with very little pain, or

2. You can try some heroic measure like chemotherapy for a minuscule chance of a multi-year moderately happy, but extremely painful survival.

Humans are programmed to have hope, and, regardless of any logic, the vast majority will choose option 2. It's just like playing the lottery. Even now, as I think about those two options in good health, I am compelled by my nature to choose option 2.

It is obviously a personal choice but situation #2 may be worse than you imagine.

You can write, read, and interact but only for a few hours each day. Pain and fatigue take over the rest of the time. There is also so many little things you take for granted you will not be able to do anymore, or will require assistance to perform. Eating can become a chore, you may have to be regularly plug to some gruesome apparatus, also loss of mobility. Think about the last time you were sick, or injured, think of the worse moment being your new normal. I personally can`t imagine being happy in those circumstances. I choose #1.

Each person choices should be respected, and people should be better informed on the tradeoff of each choices, which I feel is not the case in our health care system.

I can't imagine not doing #2 unless I'd also be non-functional during the extended life period. If I could read, use the Internet, write, talk to people, etc., it seems like it would be worth pain (which will end when you die, no matter what).

The only case where I could see #1 being a reasonable choice is if #2 puts such hardship on those around you that their lives become much worse.

It is easy to say that pain would be worth dealing with but in reality the majority of the healthy public has no understanding of what true chronic pain entails. Ask anyone who has worked in long term or hospice care this question and you will likely find an overwhelming majority choosing option 1. The reality is that in the US death and dying are still anathema.

>The reality is that in the US death and dying are still anathema.

And thus with the help of the law people are made to live as long as it is possible even when they don't want to. I'm afraid that when the policy is reversed, people would be "encouraged" to quit as soon as possible (and being afraid of such reversal the society clings to the current policy).

Somehow the society just can't understand the simple thing that the decision to quit or stay is personal and not for the society to make/enforce either way.

Agreed, I can think of nothing more personal than having to make that kind of decision. I do think some safeguards are probably necessary to prevent reactionary decisions such as cases where pain or disease are temporary. At the end of the day it comes down to education.

exactly, bingo! It's like saying u'll stay married forever when your hormones are raging.

"reality the majority of the healthy public has no understanding of what true chronic pain entails"

Agree. And forget even chronic pain. Simply having a nagging pain, a bad cold, nausea, or a bad headache is certainly enough to take the joy out of many things in life. Even a drip in my throat can kill my buzz.

Nobody gets out alive, so for me it's definitely a question of quality not quantity. It's all very case-by-case however; for example my dad had major surgery to remove most of one of his lungs (cancer) and recovered and had another pretty normal decade of life before the cancer returned, at which point in consultation with his doctors he decided he wanted nothing more done. He could have had more surgery, chemo, radiation, but was clearly in the zone of diminishing returns (enduring a lot of unpleasantness for maybe a bit longer life of uncertain quality).

For me #1 is easy. Screw writing and reading, instead travel around the word, jump from planes, swim with sharks and die in months. 100% better then daily visits to a hospital for a handful of years.

What I, and a lot of people like me, are doing now by not doing #1 is gambling we'll get to do it in the future. This is an easily lost gamble, but oh well.

That sounds great but dying doesn't leave you with a lot of energy to do these things for long.

I think the point is that the treatment leaves you with a ton less energy and hunger and power, etc. Otherwise there really is no point in skipping the treatment.

Then the $19.95 home stem cell kit comes along the week after you die.

I think dhughes made a point here. I would choose option 2 not only because I have a chance to live longer, but also because there might be a treatment for my illness, which will be discovered in the future.

If the treatment allowed you to live over a decade longer then you could live long enough to get another treatment option, this has been true about AIDS drugs.

But if the treatment allowed me to live over a decade longer I'd also choose the treatment even if there was no chance of a new cure.

If the treatment only allows you two or so extra years, unless something is already in the late stages of coming to market, there is just no way any kind of drug or therapy for humans will get through even the earliest stages of approval in that kind of time frame.

At that point, it's probably still too late for you.

In case of chronic diseases like cancer, #2 does put hardship on those around you and their lives will become much worse.

Humans are notoriously bad at predicting what will make them happy.

Humans who haven't thought about it aren't, but when you've thought about it you can predict very well.

A decade of research into affective forecasting says otherwise. It shows that you'll only be good at predicting what makes you happy if you read studies about biases in affective forecasting. See "If money doesn't make you happy, then you probably aren't spending it right" http://dunn.psych.ubc.ca/files/2011/04/Journal-of-consumer-p...

The abstract of that paper underscores my point that if you've thought about it you can predict better what creates happiness.

I don't agree that only by reading "studies about biases in affective forecasting" can you be good at predicting what makes you happy.

I know if I eat good food with good friends or family I'll be happy. I've never read that in a study, but it works every single time with me. I know plenty of other ways too.

I don't think reading studies is the only way either, but I don't think most of us have questioned what makes us happy outside of soceity's default settings (money/fame/toys/vacations).

People make all sorts of tradeoffs which are non-optimal:

* Extra commute to a better job with $XX,XXX more for +1 hour/day of travel (less time for good food with family/friends) * Move away from good family/friends to pursue better job * Pursue career X because it's more lucrative than career Y (even though Y is more enjoyable)

There are lots of biases like this, under the assumption the change will increase our net happiness.

In case people think kalid is making it up, the first one is the 'commuting paradox': http://ftp.iza.org/dp1278.pdf (or http://www.businessweek.com/magazine/content/05_08/b3921127.... )

Thanks for the link! I remember reading that study somewhere. A salient part of the article:

"This is what economists call "the commuting paradox." Most people travel long distances with the idea that they'll accept the burden for something better, be it a house, salary, or school. They presume the trade-off is worth the agony. But studies show that commuters are on average much less satisfied with their lives than noncommuters. A commuter who travels one hour, one way, would have to make 40% more than his current salary to be as fully satisfied with his life as a noncommuter, say economists Bruno S. Frey and Alois Stutzer of the University of Zurich's Institute for Empirical Research in Economics. People usually overestimate the value of the things they'll obtain by commuting -- more money, more material goods, more prestige -- and underestimate the benefit of what they are losing: social connections, hobbies, and health. "Commuting is a stress that doesn't pay off," says Stutzer."

That article was so good I made a separate submission for it. Thanks.

Why would this be downvoted? It commented on a defeatist statement that is only accurate for people who don't learn about what creates happiness, thinking it's only things like more money or promotions or buying products.

I basically echoed the principle of "know thyself" in a relevant context.

I voted it down because it's an "argument from authority" and I found it slightly pretentious. It was also ironic, considering your other comment today defining "argumentum ad verecundiam". I didn't really like Kalid's statement either, but left it alone.

As you say, you are echoing a principle (which verges on a platitude), but not adding a lot to the discussion unless we are willing to trust your expertise without examples. Had you combined it with your more detailed followup, I wouldn't have felt this way.

I'm not really defending my vote, just explaining my thought process since you were asking. If it helps, I've evened out my actions up by upvoting this question.

People frequently choose #1 half way through #2.

I don't think they do it consciously, but doctors try to sell you on their philosophies for healthcare.

No, doctors try to make you as fully aware as possible of the options available to you, so that you or your heirs don't turn around and sue them later for 'withholding information that could have saved your life' or something along those lines. Arguably, these suits are motivated in part by the need to defray the extremely high costs of care and pushing back at the physician or caregiver about the quality of clinical care is a powerful negotiating strategy because it plays well to a jury.

"Lawsuits" are an easy scapegoat, but it's probably not a significant driving factor. For example, Texas has very strict tort reform laws which basically make it impossible to sue a doctor for malpractice. But defensive medicine hasn't faded at all in the four years since those laws took effect.

Structurally, our system is designed to over-treat. With co-pays, insurance, subsidized care, and contractual discounts, patients seldom are aware of the exact cost of treatment. How often do Doctors explain to patients up front both the tests to be performed and the line-item cost (both to you and to the payor) of each?

Most doctors don't, and realistically can't, know the cost for each patient under each plan. Usually, it's a binary decision for the doctor (covered or not covered).

Try it sometime. When your physician suggests a procedure, ask what the real cost is, and whether he/she thinks that the value of the results will be worth the expenditure compared to alternatives. It's simply not something that's "baked in" to the thought process of the medical profession either in medical school, residency, or thereafter.

I agree lawsuits are not the primary or even a major driver of costs, but every doctor I've met worries about them, and I was responding to speculation about what motivates doctors as individuals.

As for Texas, you're quite right - indeed, medical costs seem to have risen since the 'reforms' were put in place: http://www.dayontorts.com/tort-reform-medical-malpractice-to... - according to a tort lawyer, but consistent with everything else I've read on the subject.

Probably most of us belong into "Dum spiro, spero" category, but I have known some non-doctors who have taken option no.1 (painless death) and even accelerated it.

"Dum spiro spero" => "While I breathe, I hope" - for those of us who don't remember their Latin training, myself included.

Well, when winning the lottery means living and losing equals the same thing as not playing; I'm going to play every single time.

But it does not equal the same as not playing. The end result is the same - death. Heck, the result of all three possibilities is the same. But the difference is in the length and quality of life leading up to it.

Given the choice between now and couple years of pain later, I currently see myself choosing the former. I don't want to go through the process of becoming a disease-worn shadow of myself, and neither do I want to be remembered as one. Maybe that will change with age.

That's your ego talking, worrying about what other people think of your choice. As you get older, what other people think starts to lose its importance.

Having had 2 brushes with suicide, and multiple times being reduced to destitution, I've since learned that life is not defined by happiness; it's defined by experience. And pain is just as valid an experience as any. In fact, I'd argue that a life without pain is a life wasted. There will be joy and there will be sorrow, but every second of every day, your life ebbs just a little. It's barely perceptible, until you discover to your shock that 10 years have somehow got behind you without you noticing.

And that's when you realize that it's far better to live a life of pain than to live a life of regret, or even worse, no life at all. A random chance ignited the spark of life on our planet. It's amazing you're even alive at all, let alone able to contemplate it. Life is allotted to you in limited quantity. Guard it jealously and live it fully, regardless of how it feels. There's no arbiter at the end, except for you, saying "I lived my life to its fullest."

    "I lived my life to its fullest."
That's the point he was trying to make. You can't live much when you're strapped to a bed on painkillers.

That's opinion, and opinion shapes what reality you see. Changing your opinion is hard, but it can be freeing.

Only equivalent if where you buy lottery tickets they jump over the counter and beat the crap out of you every time you buy a ticket.

Especially when someone else is paying for all of those lottery tickets.

The choices are very binary. A right choice would be option 2 with right to die if things don't turn out as planned.

Tonight I will tell the mother of our child that if I reason in any way that resembles this article she should slap me in face and tell me to fight for my life. For my daughter and my own sake.

In Sweden medical care is free. I can fight as long as I want without them getting in trouble. I also suspect I should fight so hard as if the illnes is truly terminal I will end sooner in flames, not later.

I want all the tubing. I want the cracked ribs and surgeons transform me to a piece of blubber and then anlyze the hell out of it so anyone else don't have to go through the same thing.

Telling people to give up because of money or some sort of gentleness to yourself or your family is alien to me. Maybe it's our harsh climate uphere. Swedes seems very in tune with our suffering.

"In Sweden medical care is free. I can fight as long as I want without them getting in trouble."

It's not free. It's free to you, but it is placing additional costs on the Swedish medical system, which somebody is ultimately paying for. You don't have to internalize the costs of your decision.

I'm not arguing whether or not you're a making a good or bad decision, or whether or not "free" medical care is a good thing. I'm just pointing out that providing such a system skews decision making.

Free or not, it seems to work pretty well for the citizens there. You don't have a sizable portion of the population filing bankruptcy over medical bills and they haven't gone bankrupt like Greece. Something Sweden is doing is right.

Greece has socialised healthcare, as do the rest of the European countries circling the drain. http://en.wikipedia.org/wiki/Health_care_in_Greece

It's worth noting that the US health model isn't a free-market system - the state links health care to employment, which distorts the market away from individual private health ownership, and creates patterns that make it easy for costs to creep up. The US health care model is a disaster: the state doesn't supply health care, but then also prevents the free market from operating effectively.

The EU countries that are not circling the drain also have socialized healthcare, for the most part. Healthcare is a driver of public sector costs, but hardly the only one.

Yup. That's why I thought the Sweden/Greece thing above was odd.

Nice job blaming socialized healthcare for the greek situation. Has there been a single serious or unserious comment blaming their problems on socialized healthcare? Glenn Beck wouldn't even do that.

Germany has socialized healthcare too, FWIW. Cheaper cost per capita than our system, with better results.

The state does a lot of other things too, like setting the ratio of a GP's pay to a specialist's pay to something much higher than in other countries, and letting pharmaceutical companies charge whatever they want in the US market but banning the re-importation of drugs from companies where they're sold far more cheaply.

Ireland has an extremely poor socialised health care system, and is in trouble right now. By your logic, the fact that the health care system was gutted in the 1980s should have allowed Ireland to avoid these issues. Sadly, it really isn't that simple.

How is the state linking health care to employment?

My understanding is that health care is linked to employment because of the adverse selection problem that occurs in a free market of individual health insurance. Can you elaborate on why you consider this to be the government's fault?

Health insurance is not taxed when a company pays for it, but individuals need to pay for it with after tax dollars.

Assume you can sign up for plan A at your company that costs 200$ a month and covers everything you want. Or you can buy Plan B which costs 180$ a month for the same coverage.

Assuming your marginal tax rate is over 10% then plan A costs you less money. Now, most company's bundle healthcare so it's harder to get that money out of the equation, but for small company's it easy to negotiate if you can get heath care cheaper though your spouse etc.

    > How is the state linking health care to employment?
During the second world war US wages were frozen. But there was an exception where you could provide employees with differing levels of health care. So that became a mechanism for competing for staff: it became common for companies to offer corporate health care at the same time that individual private health was dropping off because nobody had any money to afford it. This pushed the market towards group-based programs. After the war, public policy further cemented the patterns that had developed.

I understand that if you live in the US it's impractical to get private health insurance on an individual basis because there's low business in the space, meaning low competition, as well as the tax structures described by other commenters.

    > My understanding is that health care is linked to
    > employment because of the adverse selection problem that
    > occurs in a free market of individual health insurance
I'm not familiar with this effect, which isn't to say that it doesn't exist - don't know. Certainly there were healthy private health markets in countries I'm familiar with before the age of government intervention.

The adverse selection can be solved a different way: legislate that health plans have to be open to all comers and regulate price differentiation to a few key cost drivers that are politically viable (eg smoking).

As would a pay-for-treatment medical system, like in the United State, which simply skews decision-making in a different direction.

(Or, if your uninsured/indigent, reduces the choices you have available to make a decision between anyway)

My mother succumbed to cancer over 10 years back. I was in my late teens and remember the treatment being way more painful than the cure. The medical care was so bad in india that once the nurse messed up the chemo shot and delivered it wrong. This resulted in oedema. Doctors could offer nothing more than an apology. I still find a lump in my throat when I recollect those days. However, in the end, my mother rejected treatment. She did however wish to live a long life. But she could not bear the treatment. Doctors gave her 2 months. But she lived on for 8 more months on painkillers to maintain as normal a life as possible. She managed to remain cheerful and positive before us kids. Living with someone you love knowing that they would die soon is really painful.

If I am terminally ill, I will probably reject treatment and choose to go peacefully.

"For my daughter and my own sake."

Your family is your business, but I have watched both friends and family die fighting hard in the ICU. It would not have been my choice to watch them, nor for them to go through that for the sake of myself.

Fighting for the sake of fighting alone has no value.

Watching a loved one suffer is agonizing.

Medical care is free, but it too has a limit. There is a finite amount of money available for treatment, and there is an almost infinite amount of new, unproven treatments that might just work.

Lots of people put themselves into debt trying alternative or experimental therapies, even in countries with universal healthcare. The sad truth is that whatever kills you will probably not be something that the doctors can learn much from. It will be some disease that is well known, with lots of data on survivability etc.

Interesting. I found myself responding to the article in much the same way as you. Also Swedish. The question is: are we being rational or deluded?

I have friends who are medical professionals and I don't recognize them in this either: I highly doubt any of them have NO CODE tattoos or anything equivalent. I suspect society shouldering most of the cost might be a factor: with a privatized payment system, there are perhaps incentives to go too far that aren't there when there's no profit to be made? That's pure conjecture, though.

This is not a question of being "rational", and there's no right or wrong answer. People make trade-offs between quality and quantity of life every day. Do I want to quit smoking, drinking, drugs, and take up sports, etc for a chance at a longer, healthier life? Or do I grab all the fun I can, and if it costs me ten years, oh well? The right decision will look different for every person - and it's not black or white, but a continuum.

The choice of how much pain is worth it for how much of a chance at a longer life is going to look different depending on your religion, your responsibilities, your age, your experiences with pain, your family, your culture, etc. And yes, of course the cost of treatment will factor into that decision for both the doctors and the patient.

It can be a rational or irrational choice depending on the available treatment and the specific case. A blanket statement that says "do not resuscitate" ignores cases where resuscitation could have been successful and where the chance of revival outweighs the risk of undue pain and suffering.

In a world where the only available treatment is blood-letting or getting your limbed sawed off by a hacksaw, a "do not resuscitate" policy is clearly more rational than in the Star Trek/sci-fi world where treatment consists of a doctor waving a magic iPad over your head and nanobots cure you painlessly. Since we're somewhere in between those two it becomes more complicated, but evaluating the risks and benefits and making an as informed choice as possible based on the available information still seems to me to be the rational way to look at it. Making future medical decisions based on an emotional reaction to individual cases, on the other hand, seems to me to be irrational and counter-productive.

I'm an american and for me, it's not an issue of cost. The issue is how do you want to end your life on this earth. My father died of lymphoma when I was 17; he got it twice. The survivorship rates if the first set of treatments didn't work were not awesome. In his case, he died after multiple rounds of chemo and radiation and surgeries, incisions that didn't heal for multiple months, collapsed veins leading to a shunt installed in his chest, persistent nausea for half a year, so much pain that if properly medicated he was barely lucid, being forced into a wheelchair, having to wear a diaper, bleeding from his eyes and mucous membranes, etc.

Having seen his tour of the medical system, I desperately hope that if I were ever in that position, I'd have the strength to say no: treat the pain and I'll die in peace.

I don't think the issue is the cost to the patient, but rather that in a private payer system, it becomes profitable to keep patients alive for as long as possible. In a public payment system, you could crassly say that keeping patients alive is a cost to the system. Now, that would seem to imply that the public option might lead to early termination of treatment in cases where treatment would be feasible but expensive, and perhaps that does happen.

Here, here. I'm from Australia where medical care is also free. This idea of dying quickly as to not burden your family with medical expenses is ridiculous, given the success that single-payer health care has had in many countries all over the world.

I understand that some conditions cause insufferable pain with very slim chances of surviving, but there are many success stories from people who have battled through. Its often these same people who provide the courage to others to battle on and raise money to support the families of those who have had similar experiences. We shouldn't be thinking about optimising our lives for our own happiness, but for the generations yet to come.

I will always fight for my life to the bitter end. There is no way I would leave my children to come to grips with why their father gave up without a long, hard fight.

It's not free, public hospitals are overcrowded and full chemo etc costs a lot. Fight to your last breath if you want to but the point of this article is that doctors themselves think that on average you will be happier living your final days without extreme treatment. All the miracles you've heard of are effected by reporting bias.

In Sweden medical care is free. I can fight as long as I want without them getting in trouble.

I thought Sweden had committees to decide on what standards of care would be provided or not, preventing you from making the mistakes discussed in the article?

EDIT: Also, remember that the US government spends more per capita paying for people's health care than Sweden, but manages to spend that huge amount of money on only poor and old people who don't have employer-provided health care.

So, I'm living in a country that has public health care too, worse than Swedish, but oncology is pretty well funded.

I also have "fight for life at all cost" experience, though only with animals (I provided a kitty foster home, and through that assisted in a vet clinic somewhat). It's not like with humans, but enough.

I have also seen my grandfather's last days, so maybe that influences me somewhat.

If I ever get cancer, barring some incredibly lucky circumstances when it's completely resolvable, I will avoid treatment. The suffering is not worth it, and the pressure on the loved ones is not just financial.

I don't think we've read the same article. It's not about money.

Have you ever been hospitalized? How old are you?

Telling people to give up because of money or some sort of gentleness to yourself or your family is alien to me. Maybe it's our harsh climate uphere. Swedes seems very in tune with our suffering.

It's not about being tough and macho. A lingering decline can be psychologically painful for everyone involved. Pretty much everyone I know that has been involved in caring for someone who suffered a slow decline - particularly alzheimers - don't want to go through that themselves.

You say now that you may want all the tubing and to be bounced around from doctor to doctor (not all of whom know what they're doing, by the way), but it's a very different beast when you're actually experiencing it. Some folks just say 'do what you gotta do'. Others say 'I don't care what you think you'll find with yet another test, the endless battery of tests is worse than the disease'.

A lingering death can sometimes be easier for those round about you, to some extent. They know what's happening, get a chance be resigned to the future, but still talk to you before the end. And if it's painful, they can feel relief that your suffering is over.

When you die quickly, you personally don't suffer, but those around you are stunned by the sudden, often unexpected loss and life. It seems cruel and arbitrary.

My mother died of a sudden heart attack at home. It was so sudden that she seemed perfectly fine that very afternoon and evening according to everyone who had seen her that day. It was a shock to hear about. On the other hand, my father died, unconscious and hospitalized, after a week of unsuccessfully trying to recover from emergency surgery after months of intensive medical treatment and going in and out of hospitals. Speaking from experience, I think a sudden death is far less cruel to your loved ones. At the very least, it doesn't require them to make tough decisions.

You never get a choice, though. Some people, like my father, survive their first heart attack with no apparent long term damage while others, like my mother, don't. Some people get cancer. Some people even get hospitalized for things that aren't life-threatening--but when something life-threatening does happen, those medical problems become obstacles to effective treatment.

It may seem counterintuitive, but I think the opposite is true. Think about it: what will people remember about you? If your death is relatively quick, the majority of their memories will be of happier times spent with you in good health. On the other hand, if you have a long, drawn-out, multi-year struggle, that will be what they remember most.

I don't have the link handy, but there was a study a while back comparing hospice care to class 3 chemo (that's the really, really poisonous bad stuff). The study found that families of those who went into hospice coped better with the loss. Furthermore, almost counterintuitively, those in hospice care actually lived longer on average. Sometimes, taking stress off the body gives it just enough room to keep fighting on its own a bit longer...

This is my experience.

I've lost friends to sudden deaths -- usually accidents. It's a bolt out of the blue, but it's over quickly and there's rarely much suffering.

I've lost family "after a long illness" as the news reports say, and the roller-coaster of misdiagnoses, initial treatments, exploratory surgeries, continued uncertainty of diagnostic monitoring and procedures, hope for treatment advances, false hope from charlatans and quacks, relapses, remissions, and the final, inevitable, unstoppable, and increasingly debilitating decline, tears people, families, and communities to pieces.

I've also seen cases where the end was known, but treatment brought, at a relatively low cost and with little dread or pain, an extra six months of a life that was happy and full of love. In that case, not so bad.

There's a difference between a quick "he was fine this morning" death and a quick "gone in two months" death. The idea of letting the disease take it's course with only comforting care gives people time to say goodbye - it's mentioned in the main article as even being able to give more quality time with loved ones.

I was married to a doctor for 10 years. Before that, I lived with my aunt, also a doctor.

The one thing that absolutely shocked me is how they thought about aging and death. I kept reminding them their goal should be to find cures for everything, no matter how hard it seems. I approach every engineering problem as solvable. Maybe I can't solve it right now with the tools I have. Maybe I can't figure out a way to solve it and will have to leave it for the next generations. To absolve yourself because something is inevitable is a coward solution.

So, no, thank you. If that's what it takes to survive, I want to be cut open, sliced, probed, and, when everything else fails and I finally die, I want doctors to learn something from my death. I want them not to give up and, if they can't treat some condition, go out and invent a way to do it. You don't give up solving a problem just because it's hard.

It's their job and it's reasonable for us to expect them to do it.

I think this is a great way to think about it. People who try everything to extend their life do not die in vain. Over ten people in my family in the last ten years have been diagnosed with cancer and so far we've only lost one. The person who didn't make it was the youngest of all the victims, but his tumour was also somewhere the doctor's didn't see that often - the bile duct near the liver.

The number of operations and suffering he had to endure still lives with me to this day and I could see why any doctor would choose not to go through this if they had to see such futile attempts at extending life end the same way. They flew in special equipment from the USA that was deemed highly experimental and would cut him open and try it out, only to have to cut him back open a few weeks later to remove what they put in. They tried surgery after surgery in the hopes something would be successful. They did not save his life but I like to think they at least learnt something about a cancer they simply don't see that often, that gave the next person a better shot. When they finally told him there was nothing more they could do, he asked them to stop all further treatment and to let him die on his terms.

The outlook for patients with breast, stomach, lung, testicular, skin or any other form of "common" cancer used to be as bad as pancreatic or bile duct cancer, but these days it's not a death sentence and a lot of people had to lose hard fought battles to get to this point.

Every single one of us are going to die at some point. If you were a doctor and your goal is to "find cures for everything" then your eventual success rate over your career would be 0. Do you realize how hard it would be to do that for your entire career if you approached it thinking you could beat cancer?

You don't say in your post if your relatives were practitioners or research doctors, but if you're putting it on a practitioner to think they can beat the (studied) odds every day it is unfair in the least.

We are greatly indebted to the people who choose careers this stressful that benefit everyone else. You don't need to blame them for the current state of medical science. Trust me, they do it to themselves more than enough.

Since my father died, 43 years ago, many types of cancer were defeated. He wouldn't die today - he would undergo chemotherapy, radiotherapy or surgery, would go bald, but would live to see his grandchildren.

their goal should be to find cures for everything

That's certainly a medical scientist's goal. It's not all the same as what I expect from a regular doctor, whose job it is to look after me - making a best effort to find or suggest cures where that is practical, or to minimize my suffering where it is not.

How old are you? Have you ever been hospitalized? Undergone surgery? Had other invasive medical treatments?

People should differentiate between terminal illnesses and acute illnesses like heart attacks. For the later, I am sure the OP has no problems with treatment.

The leader of the breakaway Republic of Biafra died this week. He was less than a vegetable for 8months until his death. Here was a man who was larger than life reduced to helplessness. At the age of 78, I am wondering why he was tortured for these 8 months so he would be 'alive'.

I am certain if he had the choice, he would have preferred to go with dignity. Unfortunately, people never want to prepare for such things. When it happens, their end is determined by others.

My President Yaradua, also had the most undignified of ends possible. In theory Ariel Sharon is still alive. http://en.wikipedia.org/wiki/Ariel_Sharon

I want my end to be dignified. If God forbid, I have a terminal illness, it will not be a hard decision to make. Quality NOT Quantity.

Both of my grandfathers died in the past five months.

The one who lives halfway across the country was 97. He woke up at his lake cabin the morning before he died complaining of chest pain and shrugged it off but was soon being transported unconscious to the hospital accompanied by his paramedic neighbor. He slipped into a coma and the next day with several of his children at his side, was removed from the ventilator.

My other grandfather, who lives in the same town I do, was 93 and had struggled for the past several years with a progressively debilitating illness which increasingly kept him from being able to do the things he wanted to do. A couple weeks before his death his health took a turn for the worse and he quickly began losing connection with the world. He did go to the hospital and tests were done and drugs given, but we soon understood that he wouldn't recover and we brought him home. The hospice nurses and caregivers were wonderful. All his children came as did many old friends. He died in his sleep in his bedroom with his wife and children there.

Both had advanced directives requesting minimal effort to prolong their lives. My grandfather here wanted no heroic efforts and "no machines". Even so, a lot of intense discussion among his children was involved in coming to peace and/or acceptance of what exactly that meant, what the moral and ethical implications of different interpretations were, and how best to carry out his wishes.

This is what I'm now doing and what I strongly encourage you to do now:

* Create an advanced health care directive for yourself. You can get forms and examples online.

* Consider the various situations one might end up in and lay out as explicitly as you can what you'd like to be done or not done to you. The more specific you are, the more likely your intentions will be followed and the less your family/loved ones may have to struggle with the interpretation.

* Talk to your your family and loved ones about your desires. It's a hard and awkward discussion to have but do it. Be clear and frank.

Takeaway: Have an advanced directive. Be as clear, specific, and explicit as you can about your desires. Share your desires with your family, loved ones, and care providers. It is helpful not only you but form them as well.

I'm conflicted about this. On the one hand I don't want to be hooked up to a ventilator or go through extreme suffering to prolong life. On the other hand, my grandmother (who recently passed away) went through late stage breast cancer in her mid-50s, lung cancer in her 60s, had a severe heart attack in her 70s and died in her 80s. It was so bad one time the doctors told us she would die in a matter of days. After she recuperated, she lived another 8 years. She was a tough bird.

How many times have we all heard: "The doctors gave him 6 months to live and that was 5 years ago". So if I knew I could go through 3-6 months of severe pain and get another 5-10 years of high quality life with my family, I'd probably do it. The problem is you may go through 3-6 months of severe pain and then die in month 7.

Right now being in my mid-30s and with a young daughter I enjoy, I'd take on the fight. If I was in my 80s, probably not.

How was your grandmother's quality of life in those last 8 years after the doctors said she had just a few days left?

As for "The doctors gave him 6 months to live and that was 5 years ago," keep in mind that you get a horribly biased sample. People don't generally go around saying "The doctors gave him 6 months to live and he died 6 months later," even if that may happen far more often.

Just this weekend I met a relative on the street (mid fifties), doing some shopping. A few months ago, he had some chest pain, his wife thought it was a heart attack and drove him to the ER. As he was being admitted, he went into cardiac arrest, he was resuscitated, and now his four teenagers have their father back, for a few more years at least (he is back at work, and seems to be living a full and healthy life). What's interesting about this, in relation to the OP, is that his wife is a doctor, and she was the one who resuscitated him.

Yes, it's just an anecdote, but a useful one to balance against those in the OP. Obviously the situation differs if you have a terminal illness, or other serious health issues, but I think a blanket NO CODE rule is a little extreme.

"terminal illness" is the keyword here and what "no code" is associated with in medical terms. A heart attack, a stroke and similar acute traumas should definitely be treated. These patients may live a close to a 100% life afterwards.

> I think a blanket NO CODE rule is a little extreme.

That's because it's something of your own invention. No one is advocating this, especially not the health professionals involved.

No one is advocating this, especially not the health professionals involved.

...except when they wear bracelets and tatoos stating "NO CODE".

Making a choice and making sure that choice will be noted when the time of its relevance comes is not 'advocating'.

The situation you are talking about is very very different from what the OP is talking about. But yes I agree, a blanket NO CODE rule is extreme.

"It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment."

I strongly disagree with this part. Before patients become patients, the vast majority of us have no interaction with the health care industry and certainly no significant capability to influence it. Doctors, on the other hand, spend their adult lives working as professionals in the industry. To say that they, as a group, are anything but complicit is wrong.

Consider the "Fuck passwords" article[1] that's on the HN front page now. As a programmer who has dealt with passwords, the sad state of authentication is, in part, my fault. I could make the same excuse, "Well, the users don't want long passwords, and Facebook and G+ are part of the problem, and blah blah. I'm a victim of a larger system" That would be lame.

Like the doctors, I'm one of the professionals in the field, so it's my responsibility.

[1]: http://news.ycombinator.com/item?id=3313790

This is obviously a very personal topic, but I can't help but ask whether medecine benefits from people undergoing "futile care"? Are some diseases only treatable today because 20 years ago someone went through all the crap?

The whole thing reminds me of the average mid-90s movie Phenomenon. I could always understand Travolta's character's reasoning, but I still thought it was selfish.

Science doesn't work like that.

To get meaningful results you need a large sample size, with a control group, with patients not knowing whether they're getting the new medicine or the old medicine[1] and with doctors not knowing either. Then you need to write that up and analyse it.

Many patients are happy to take part in such trials, but it's hard to get ethics panel approval.

[1] you tend to test against current best treatment, not placebo, because almost anything works better than nothing and by the time you test the treatment in humans you need to know if this is better than what you're already doing.

Ethics panels have some weird effects -


That's how it works in the best case. Unfortunately, medical research is not a perfect science. Realistically, with many medical treatments, you can't have a double-blinded study. With chemotherapy, the side effects will often quickly tell you what treatment you're receiving, and a treatment like for example extracorporeal photopheresis can't ethically be placebo-controlled or double-blinded at all. What are you going to do, hook half your patients up to a machine that will do nothing but run their blood around a bunch of tubes for hours for no reason?

And you can't get a "large sample size" of patients with rare cancers or diseases by definition. Sometimes, the best you can do is a case study of ten patients who agreed to try your treatment because the other option was death. Quite a few medical advances have been made that way, actually.

Science is rigorous, repeatable observation. Double-blind studies and null hypotheses are excellent ways to achieve this. But case studies and low n studies are also informative - and are science. That science can only be control groups and null hypotheses is a myth.

Try and tell the medical fraternity that case studies should be eliminated because they hold no meaningful result and you'll be laughed out of the room.

Case studies are lousy because they are not rigorous, and often have not had any meaningful result.

See also knee arthroscopy for patients with osteo arthritis - many of these surgeries were performed before a trial with a control group was possible. That trial found that people who got the sham surgery did as well as the people who got the real surgery. Case studies are lousy, often harmful, medicine.

The thing is that you read case studies with this caveat in mind, recognising that they're statistically flawed. When you don't have better information available, case studies and low n studies give some direction, some previously observed information.

Medical research benefits hugely from terminally ill patients who are willing to try anything for even two more months of painful life. There are a lot of of experimental, highly dangerous cancer treatments that could never be justified if not for the fact that even without them, the patient would have about two months to live.

That said, there will always be enough patients who want to fight for their life no matter the cost (see other comments on this page for evidence) that if you'd prefer to die in peace, you certainly shouldn't feel obliged to play the guinea pig for science.

I think there are examples of what you're saying. I remember reading in "The Emperor Of All Maladies", by Siddharta Mukherjee, about experimental chemotherapy treatments that initially only extended the patient's life by 6-12 months. Later, as science advanced, combining these with new therapies greatly increased the survival rate.

But in the end, it is an individual choice. There will always be some who choose to fight no matter what (and they should be aware of their chances) and there will be others who prefer to let go.

I'm a medical doctor and I'll never forget what one of our respected (and elderly) liver specialists said when asked what he would do regarding a patient with a liver cancer with a particularly poor prognosis. During a roundtable discussion, various younger doctors came up with lengthy suggestions and lots of different chemotherapy regimens, tests, etc. When it was this doctor's turn to speak, he said: "Well, if I were to put myself in that man's shoes, I would go to the store, buy a case of fine liquor and drink myself happy for the next few weeks until I'm gone."

He had seen enough "therapies" to know enough when to forgo them.

Sometimes knowing too much can be bad for choice making.

As a coder, I worry every time I drive that the computer could accidentally fire the airbags because of a bug in a poorly coded sensor (this happens far less frequently now but when airbags were first introduced people were killed/injured periodically http://news.google.com/search?q=airbag+recall+deaths ).

Not the best example but things like this do affect choicemaking and corner-cutting. It's like the fable of the plumber's plumbing, never being in good shape despite his expertise.

Hence doctors probably don't always make the best decisions about their own healthcare because they are either over-reacting, or under-reacting.

The CPR example that's used throughout the article is a bit weird, isn't it? Isn't CPR performed when someone has no heartbeat? What does it matter if you crack their ribs? It's only painful if the person survives.

I'm not debating whether people should attempt to prolong their lives with aggressive chemo, just picking a nit.

If I was in an accident or an illness today -- I'd want them to crack my ribs and so on. In 50 years or so, when I'm 80 and in poor health I'm not sure I'd want the same thing.

Yeah that's the author's point. Chronically ill or terminally ill patients receiving heroic care, not an otherwise healthy 30 year old who has an acute illness.

If you're 80 and in poor health, recovery from broken ribs is likely to be extremely difficult and painful.

CPR is done on unconscious people who are not breathing. They may have no heartbeat, or it may be an irregular one. CPR shouldn't be done on someone that can feel the pain at the moment of the ribs breaking, correct.

What's the message here? That people shouldn't have chemotherapy? That we shouldn't do resuscitation? That all advanced cancers should just receive palliative care?

This seems to be a rant ie. the author has a strongly held notion that he has disguised as an argument devoid of any nuance. The support for his argument is that doctors secretly run a mile away from hospital whenever they get sick. This is not true and a gross generalisation.

Cause guess what, not everyone has a loving family or a house in the hills or a cousin with a big screen TV to go to when they are dying from a terminal illness. Some people want to try and fight their disease, and they are tenacious and brave and admirable and that's dignifying to them and to those that try and help them.

This article is an attempted justification from someone who has lost faith in what they do, nothing more.

The message is that there is another choice.

I read it as giving people a different perspective on end of life care. The system is heavily biased toward all out medical care. This article show the other side, using as examples people who have a better understanding of the tradeoff.

This decision will always be a personal one, there is not right or wrong answer, just different possibilities.

Two related stories I thought of while reading this:

1. A Pacemaker Wrecks a Family's Life - http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.htm...

2. A Tale of Two Hearts - http://thestory.org/archive/the_story_111811_full_show.mp3/v...

The second is an audio program.

One alternative that hasn't been mentioned here is cryopreservation. Once I have the resources and the technology has progressed, I'd certainly choose that option above being treated and "NO CODE".

Totally on board with cryonics, it's really depressing that it gets swept under the rug considering it probably has at least 5% chance of working for a patient suspended today. Though your excuses for presently avoiding it seem pretty flimsy unless you're really dirt poor (I'd wager unlikely), especially when life insurance payable to the cryonics company is cheap (you only need $28-$35k for CI) and so are membership fees ($120/yr or $1,250 once for CI; I spend more than $120/yr on fast food). But don't get upset, my excuses for not being signed up yet are pretty flimsy too.

Setting aside how completely fictitious that 5% is, here are my problems:

1. Cryonics is the sci-fi version of Pascal's Wager. If cryonics is rational, than by the same reasoning so is Christianity.

2. Cryonics doesn't guarantee quality of life. If the brain is poorly preserved, you might be woken up in the far future with profound and irreparable dementia. And I mean "irreparable" not in relation to the limitations of medical science at a given future date, but in a purely information-theoretic sense. There might not be enough information left in your flash-frozen brain.

3. Cultures don't evolve because people change their minds, they evolve because people die and become outnumbered. If there's one thing the future doesn't need, it's us. And likewise, I think we would be shocked by the future.

4. Even if cryonics is theoretically feasible, I would need pretty good assurance that the cryonics company weren't charlatans. The news so far on that front isn't promising.

1. While Christianity hasn't changed, science & medical capability is increasing.

2. This concern is legitimate. There are going to be people that do not have good quality of life, or even a good brain, after being brought back from cryonics. It's a price.

3. You're arguing for the status Q, not because it's the best, but because it's all we've ever known. I think everyone who is cryonically frozen is ready to be shocked by the future. They understand moral relativity and how it varies with cultures, and they're ready to see what cool stuff our descendants will come up! After centuries of being frozen, I think that it will be legitimately interesting to meet someone from our age, and we may still be able to find a place in that world. I also think that we should be looking at what's best for the individual being frozen, not what's best for a hypothetical culture in the future. If I am reawakened in the far-flung future, I don't have any grand plans of reverting their culture.

4. I met a former employee of Alcor at a conference. She was also signed up with Alcor, and was currently working on cryonically freezing other tissues. She knew her shit, wasn't just locked into cultish thinking, and believed that there is a decent chance of some cryonically frozen people coming back.

1. Pascal's Wager isn't comparable here for a number of reasons. You're probably thinking of the reasoning some people give that a finite but humongous expected payoff justifies a finite but minuscule probability. I would agree that's a pretty stupid reason to do things; if it's worth doing there are probably better reasons.

2. It's not a guarantee, has anyone ever said it is? Hence my own estimate of at least 5%. (I believe I originally got that figure in my head back from http://www.overcomingbias.com/2009/03/break-cryonics-down.ht... -- I don't think it's an unreasonable one.) It's still a better shot than being buried or cremated and worth it given the low prices available today.

3. I look forward to being shocked. I'm not going to touch your horrid comment that death is somehow necessary for progress.

4. Cryonics is a pretty poor business to be in if you're a charlatan. Where are you getting that vibe from?

While remembering that old post I linked I also found this comment I thought I'd share from a "Luke" ( http://www.overcomingbias.com/2010/07/cryonics-as-charity.ht... ):

Cryophobia is pure evil. It makes people choose death instead of cryonics. It makes cryonics more of a struggle for those who are not wealthy; it deprives the poor of the scaling effects that would make it affordable. It deprives those who are courageous enough to try it of their dignity and attacks their character unjustly and without evidence. It splits up families. It diminishes the chance of the technology working to 5% of its potential. It is unfair to AIDS and cancer victims who must die an early death permanently because of this. It misrepresents facts, repeatedly, while masquarading as skepticism. It has no shame, no decency, and no honor.

> Pascal's Wager isn't comparable here for a number of reasons.

Please provide them.

> Hence my own estimate of at least 5%. (I believe I originally got that figure in my head back from http://www.overcomingbias.com/2009/03/break-cryonics-down.ht.... -- I don't think it's an unreasonable one.)

I guess if you invent a few data figures and then do math on them, you can get an aggregate of your own opinion. It's like the Drake equation, except at least with the Drake equation there are some terms we actually know.

> It's still a better shot than being buried or cremated and worth it given the low prices available today.

Every dollar you pay for cryonics is a dollar that you're depriving your actual living children or family members, or it's a dollar you're depriving yourself of in the past modulo time value of money.

> Cryonics is a pretty poor business to be in if you're a charlatan. Where are you getting that vibe from?

It's the perfect business to be in if you're a charlatan! There's no way to tell if you're doing a good job or a bad job, you never have to provide any results (because those happen in the distant and undefined future), and your customers are already dead.

> I'm not going to touch your horrid comment that death is somehow necessary for progress.... Cryophobia is pure evil. It makes people choose death instead of cryonics.

Maybe it is horrid, but is it true? Ah, you don't even bother addressing that. Because as we all know, the most rational response to an argument is to accuse your opponent of "evil". It seems to me that even if you dress it up in science fiction and call it "rationality", religion is still religion.

To be fair, there's only been one example of complete freezer failure at a cryonics firm that we know of, but one failure is enough if your corpse was being preserved at that firm. (http://www.thisamericanlife.org/radio-archives/episode/354/m...)

The main reason: the decision matrix for Pascal's Wager introduces infinities; the many various ones you can construct for cryonics to win do not. (I suppose you could construct one with infinities, though I can't say I've ever seen one, and I don't think that construction would be tenable anyway.) Another: the fact that there are many constructs for cryonics decision matrices--Pascal's Wager is static in time, a "Cryonic's Wager" would be dynamic in time. Another: cryonics doesn't suppose anything supernatural--if cryonics can or can't work, there are physical reasons why, we don't just have to suppose the outcomes as baseless entities. Perhaps you should explain why you think Pascal's Wager is analogous here.

We're dealing with subjective probabilities representing confidence in prediction, so yes, we can do math on them and say "If you believe this, you must believe that if you want to be consistent." Even if all cryonics estimates are ultimately that person's prior (suggesting there is no additional information currently to update a person's estimate of cryonics working given their background information, something I think is false), we can still reason about different values.

If you think cryonics has epsilon chance of working, fine, it's not for you, and under the assumption that it doesn't work I'd agree no one should do it, but I don't think cryonics has epsilon chance of working, and I don't think it's just my prior. A secondary assumption we might make is that the future world would become horrible with us introduced to it. If we knew it would, then we know we'll never be revived, and I'd agree no one should bother with cryonics. Since we don't know that, you can factor it in as a part of your uncertainty about being revived, which is a part of your uncertainty about "cryonics working".

> Every dollar you pay for cryonics is a dollar that you're depriving your actual living children or family members, or it's a dollar you're depriving yourself of in the past modulo time value of money.

Yes... and? Every dollar you pay for "X" fits that. Do you think "This $10 could go to my friend" every time you spend $10? So what to do? The linked post, at the end, suggests a dollar-value you can assign if you only think "cryonics working" has a 5% chance:

"If you make 50K$/yr now, and value life-years at twice your income, and discount future years at 2% from the moment you are revived for a long life, but only discount that future life based on the chance it will happen, times a factor of 1/2 because you only half identify with this future creature, then the present value of a 5% chance of revival is $125,000, which is about the most expensive cryonics price now."

(And cryonics can be had for as little as $40k, more or less.) This isn't quite mathsturbation, since it's legitimate if in fact you match the stated assumptions.

> There's no way to tell if you're doing a good job or a bad job

Not true. You can rate cryonics businesses by how effective their vitrification methods are, how quick they are about it, how many patients they've lost due to any cause, whether they do any research into improving their methods as well as the currently unsolved problem of reversing it, how long they've been around, how well their facilities can resist natural disasters like earthquakes, and probably a bunch of other ways. Furthermore the market for cryonics is still very small; you stand to make a lot more money more easily doing other things, whether you're a charlatan or not. (For example releasing yet another homeopathic sleep inducer.)

Regarding your horrid comment, I'll explicitly say it's horrid and most likely untrue (but feel free to factor it into your uncertainty about "cryonics working"). If you're not going to bother defending that one, I'm not going to bother arguing against that one.

I thought the "evil" comment was interesting since the author noted it's not meant as a useful argument, it's meant as a response to useless ones. Which is what this has been. In your original comment "2" was the closest thing to an actually useful discussion point--how likely is it that enough brain information is there after vitrification? If you want to think of yourself as evil, go ahead, I wouldn't go that far but it's an interesting thought. Especially considering it from the perspective of living to 2070 (when I'll be 80), imagining that it turns out to be the year we successfully revive and fix whatever would have killed the first cryonics patient suspended in, say, 2000.

Don't conflate religion with religious thinking, and religious thinking with magical thinking, and magical thinking with bad thinking. While religious and magical thinking are both subsets of bad thinking, there are other forms, and they're all distinct from religion itself. (As an example of another issue where this "You're just a religion too!" criticism has been misused in relation to the idea of a technological singularity, see http://web.archive.org/web/20101227190553/http://www.acceler... )

> The main reason: the decision matrix for Pascal's Wager introduces infinities; the many various ones you can construct for cryonics to win do not. (I suppose you could construct one with infinities, though I can't say I've ever seen one, and I don't think that construction would be tenable anyway.) Another: the fact that there are many constructs for cryonics decision matrices--Pascal's Wager is static in time, a "Cryonic's Wager" would be dynamic in time. Another: cryonics doesn't suppose anything supernatural--if cryonics can or can't work, there are physical reasons why, we don't just have to suppose the outcomes as baseless entities. Perhaps you should explain why you think Pascal's Wager is analogous here.

Not only is it analogous, but by your own reckoning it is in many ways weaker. I don't think there's any useful meaning or distinction in describing the Christian afterlife as "supernatural", incidentally--either it's the case or it isn't. In any case, the decision matrix for Pascal's Wager is something like:

                 Believe        Disbelieve
  Christianity   Heaven            Hell
     True        (+ inf.)        (- inf.)

  Christianity   No sinning          0
     False       (- fin. net loss)
And the decision matrix for cryonics:

                Get Frozen         Don't Get Frozen
   Can Be       Get Resurrected    0
   Resurrected   (+ fin. net gain)

   Cannot Be    Waste Money        0
   Resurrected   (- fin. net loss)
Interestingly, in some formulations of Christianity, hell consists of ordinary death rather than eternal torment, which would make the Pascal matrix even more similar to the cryonics matrix. In any case, Pascal's Wager is strictly stronger than the decision matrix for cryonics, depending on how much you value being able to sin.

> Yes... and? Every dollar you pay for "X" fits that.

Well, it rather puts the lie to the claim that you have nothing to lose by having your corpse frozen in liquid nitrogen rather than buried or cremated. You do have something to lose. $40k-$125k is a lot of money that might actually be needed by your survivors. If you are ridiculously wealthy or have no children it might be different.

> Regarding your horrid comment, I'll explicitly say it's horrid and most likely untrue (but feel free to factor it into your uncertainty about "cryonics working"). If you're not going to bother defending that one, I'm not going to bother arguing against that one.

I would be glad to defend that statement: for one small example, you can just refer to demographic polling on the subject of gay marriage. Support for gay marriage is dependent upon age more than any other variable, which suggests that the passing of older generations will push the question into almost universal consensus within our lifetimes.

Now, let's be clear: this argument is against the wholesale cryonic preservation of large numbers of dead people. As long as cryonics remains restricted to a small number of eccentrics, there's no gain or loss either way; Ted Williams' severed head will not revert the far future back to 20th century social norms all by itself. If there are only a few frozen people, they will probably serve more as figures of curiosity and academic study. In fact, cryogenic preservation might provide useful information to people of the far future even in the absence of effective resurrection--by analogy, we would probably be very interested, today, to examine a well-preserved physical specimen of centuries past, just as we've been interested in dissecting mummies and ice men. But if we take the pro-cryonics viewpoint to its natural conclusion, there are probably going to be millions of contemporary people resurrected possibly centuries from now. At that point, we will have either a very large politically disenfranchised population of 21st century people or a severe shock of regressive ultraconservatism. It would be the moral equivalent of colonialism, except in time rather than in space.

From what I've seen from cryonics proponents, yourself and "Luke" included, your basic method of argument is to make wild, largely unsubstantiated claims about life after death and then condemn all disagreement as "horrid" or "evil". If that's not religion, what is?

(If you want to continue this, feel free to email me. My address is in my profile.)

1. Cryonics doesn't have to violate the laws of physics

2. You can set the terms and conditions under which you want to be woken up

3. Setting aside the lack of evidence for this claim, I want live for selfish reasons

4. This is part of the risk. But there are numerous incentives for cryonic service providers to keep their contracts

It's not exactly about the money - I'm in Europe and the only providers I know of are situated in the US. The last time I looked into it they needed a DNA sample from me in person, so at least I'd have to book a trip to go there.

But from a cost-benefit perspective, it still is pretty flimsy. Definitively one of my worst cases of akrasia.

Where did you get this "at least 5% chance of working" number for cryonics?

It's at least 3 orders of magnitude lower than that: no one was recovered from that frozen state alive so far.

Your estimate hasn't any foundation either. The question is if we can recover people in the future. The chance of that is basically an unknown. However I'd put it above religion and similar things, which makes it worthwhile.

The chance that complex technology that has never been tested - works - is very close to zero.

That complex technology is freezing human bodies in attempt to preserve it for the future.

Even if in the future recovering technologies work - non-working first step (freezing) which is done today - will kill overall process.


Even assuming you have the knowledge that the freezing process is broken, which I doubt you have, I find that any chance greater than zero is worth the investment.

I also qualified my original statement by saying that I'd do it if the technology improves. Extrapolating from past life expectancies, there is nearly a hundred years for the technology to develop until I need it. Saying the technology won't be there in a hundred years is a very strong statement.

1) By default new technology is broken (until proven working in tests). There are virtually no examples of new complex technology working without prior testing and improvements.

2) You are extremely optimistic. Life expectancy improves for about 1 year in every 5 years (I'm quite optimistic with that estimate too).

So if you are 30 now, then by the time you are 80 life expectancy would change from 78 years (today) to 88 years(50 years from now).

So basically you have about 60 more years to live if you are lucky.

No way that freezing technology would improve into something meaningful by then.

Some people on this thread have harped on cost (and used it as a way to insert their own agenda about the economics of healthcare) but from my reading of the article it is really about being free to make an informed and personal choice about what the cost/benefit of treatment in terms of life quality vs life quantity is to you.

It is true the writer writes from the point of view of his own choice, but on a topic such as this, that is really the only way to do it authoritatively.

The point of the article, I thought, was to make us think - what would I do when/if the time comes?

For everyone contemplating the prospect of hospice care vs "fight to the very end", this study might be of interest [PDF]: http://www.nhpco.org/files/public/jpsm/march-2007-article.pd...

The salient point:

> For the six patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients.

I spent a lot of time hanging around nursing homes when I was growing up, and decided a long time ago that I'd like to do fast and well before I get to that stage. The NO CODE tatoo is a great idea.

My wife is a surgeon and sees these situations constantly, a patient whose family has asked that everything be done for them. They spent months in the ICU hooked up to machines, incredibly uncomfortable and often, if they are aware, extremely depressed. And then they die. This is traumatic for everyone involved.

She (and I) would never go through this by choice. I can't stress that enough. This is not about money, this is about leaving life in the best possible way, on your own terms, with your family and as comfortable as possible.

Cached version: http://max.mu/uvwxRf

Hospice nurses helped both of my parents die as quickly and peacefully as possible. My father had congestive heart failure - a slow death over months, and my mother had dementia, and eventually started losing the ability to control her basic functions like breathing and swallowing.

If it weren't for the kind advice of my mother's doctor, who instructed all of her caregivers NOT to allow her to be taken to the hospital or be picked up by an ambulance, she might have ended up in a vegetative state in a hospital as well. He explained how it's a hospital's duty to do everything in their power to resuscitate someone, regardless of whether it's really humane or not.

It was awful watching them both die, but sitting with your family while you're given liquid morphine is much better than going through a frightening, painful, lonely death in a hospital.

While this article is interesting, it should make clear that basic necessities for life MUST be maintained. Everybody needs food and water to live by ordinary means, all medical technology aside. However, life support is not required and is considered extraordinary.

Quality of life is something to achieve with the inclusion that these basic needs are met. If not, the quality of life is a personal opinion and can be interpreted in any way, from conservative, to ridiculous.

For some reason the site is down and the cache link on google takes a while to load. For everyone that wants to read it I created a public Google Docs file with the article. You can access it here:


It would be nice if the author provided a citation or two to back up the sweeping statements he or she is making.

What are the best ways to make our preferences to our loved ones clear? Is it sufficient enough to have a living will, for example? Are there documents out there that I should be carrying in my wallet, and do paramedics seek these documents out in an emergency?

> What are the best ways to make our preferences to our loved ones clear?

Tell them. I would recommend going through scenarios with them. Everyone thinks of the persistent vegetative state, but it's very unlikely you'll end up in one. It's more likely you'll be days away from death and passed out in a haze of exhaustion and morphine, with a ventilator doing little more than prolonging this scenario. Do you want the ventilator removed? Do you want CPR if you're hospitalized for a terminal condition? What if you're hospitalized for a non-terminal condition?

> Is it sufficient enough to have a living will, for example?

It sure helps, so do that. But also make sure to designate one of your loved ones in particular as your power of attorney. Make sure it's someone who understands and is capable of carrying out your wishes. That person will stay in close contact with health care professionals and has the legal right to make any and all decisions should you be incapacitated. In my limited experience, no one even looks at the living will if there's someone with clear power of attorney telling them what to do.

This person has an even more important job, at least in the American health care system: they're often the only one who talks to all the doctors and has the big picture. If you're seeing five different specialists, and they're all talking about their own specialties, no one is necessarily in charge of the big picture. In the outpatient world you have a primary care doctor, but when you're hospitalized, this guy's out of the picture. There is probably a hospitalist in charge of your care, but just like the nurses, the hospitalists rotate on shifts, and don't really coordinate with specialists so much as just trying to keep you alive. You need someone to be power of attorney, and to take the job seriously. One of the striking things, to me, about Steve Jobs' biography was that even for him, this was true--his wife was the one coordinating the doctors and keeping in charge of the big picture.

> Are there documents out there that I should be carrying in my wallet, and do paramedics seek these documents out in an emergency?

No. I've had paramedics at my house for my dad twice, and they never looked in his wallet. On the other hand, I was there both times.

The job of a paramedic is to stabilize you, gather whatever information they can, and take you to the ER. They probably don't give a shit about your wallet or your cell phone. Whatever procedure there is for identifying someone's next of kin and finding their advance directives, it's done in the hospital. Most of the time they just ask you, if you're conscious, and they ask whoever is physically with you at the time. They would only resort to searching you and your effects if you were completely alone, or if no one around you knew anything or anyone. So designate your power of attorney and designate that person as your emergency contact at work. If you don't live with that person, make sure a neighbor or roommate or someone else you live with or close to has that person's number programmed into their phone and knows to contact them. You want a person you trust, not just a tattoo or bracelet or document, in charge here.

Very interesting story, but I do wonder if its assertions universally hold.

This looks like an excellent research question for the guys at freakonomics (http://www.freakonomics.com/blog/) to me.

Original URL does not work at this moment.


Never been a big tattoo fan, but after reading that, I might consider a big "NO CODE" tat on my chest.

Experience show that it's sometimes not enough, and if no explicit paperwork can be found medics will perform CPR anyway...

s/will perform/are obligated to perform/

In most cases, EMS in the field is operating under a fairly tightly defined set of protocols. Those protocols define what is or isn't a valid "Advanced Directive"

Is it possible that "get medical treatment" or "go in peace" is a false dichotomy?

Of course it is. The dichotomy is between going in peace and doing absolutely everything possible, regardless of costs, to live a bit more.

can someone please post this entire article or a cached version?? been trying to read what the commotion/drama is all about for the past 6 hours and I'm dying here...

Here's a link to readability: http://www.readability.com/articles/5r2ckztm

for the Ctrl-F: mirror

False. Most of computers don't calculate every digit separately but they start to test most used words then other variables. This means, Igotoschool is much easier to guess than 8h9. Hacking programs have dictionaries and most of passwords are plain words.

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