A new study of doctors’ preferences for their own end-of-life care is getting a lot of attention because it highlights the disconnect between the gentle treatment they’d want and the aggressive interventions that so many patients receive.
Vyjeyanthi Periyakoil, MD, a Stanford geriatrics and palliative care specialist, surveyed more than 1,000 doctors who were just completing their training. Nearly nine in 10 said they would not want CPR if they were terminally ill and their heart or breathing stopped. They’d want to die peacefully and naturally.
In this wish, they are not much different from the rest of us. Eighty percent of patients say they hope to avoid hospitals and high-intensity care at the end of their lives. Yet more and more people are transferred from one health facility to another or wind up in the ICU in their final days and weeks.
Perhaps because Periyakoil has titled her study, “Do Unto Others,” much of the coverage and online chatter has focused on the question: Why do doctors routinely provide treatment they would not want for themselves?
But a few other questions are also worth thinking about. Why don’t doctors want rescue measures at the end of life? And what can the rest of us learn from this?
Periyakoil does not blame physicians for the gap between what they want and what they do. Instead, she points to a health care system that “defaults” to treatment, even past the point of futility. “When there is uncertainty about a patient’s wishes or family members are undecided, the system default is to treat until there is clarity,” she said. “The current of the system is so swift that patients get swept along by the default unless they completely and clearly document what they don’t want.”
Only about one-quarter of all adults have an advance health care directive indicating the treatments they’d want or not want if they were to become incapacitated and unable to make their own decisions. As people age and get sick, that percentage increases, though not as much as you might think. A government report some years back found that fewer than half of seriously or terminally ill patients have an advance directive in their medical records.
There are many reasons for this. It’s hard for us to talk about, let alone plan for, dying. And doctors generally don’t do a great job engaging us in these sensitive and time-consuming conversations.
But we also overestimate the power of modern medicine to hold off death. We overestimate the success of measures like CPR, and we underestimate the pain they can cause. No wonder. The only CPR most of us have ever witnessed is the dramatic lifesaving efforts on shows like "Grey’s Anatomy," in which young, beautiful patients are usually revived to robust health. We never see the paddles come out for a very sick, very old patient, who, on the off chance she survives the pounding and the shock, will come out of the procedure even frailer and more disoriented. We don’t hear the crunch of ribs cracking as the doctors go to work.
Doctors hear and see all this and worse during their hospital training. And they know the statistics: only about one in five patients who suffer cardiac arrest in a hospital is saved by CPR. The pioneers of modern CPR envisioned it as a way to revive a “heart too good to die,” not to restart a “heart too sick to live.”
Would we all be better about having the difficult conversations and documenting our final wishes completely and clearly if we understood the limits, the risks, and sometimes, the torture of CPR, breathing tubes, and other aggressive interventions at the end of life?
As I read her paper, I thought about the groundbreaking work of a Harvard physician, Angelo Volandes. He has created a series of short videos to show patients what these interventions look like, so they can make more informed decisions.
The videos are graphic, though sanitized — life-size dummies serve as the patients, leaving the fright and noise of the real procedure to the viewer’s imagination. Nevertheless, his before-and-after studies demonstrate that the videos have an impact. In a study of patients with advanced cancer, nearly half initially said they’d want CPR if their heart stopped. After viewing the video, 79 percent said, just as Periyakoil’s young doctors did: Don’t try to revive me. Let me die in peace.