Doctors taking a new approach to dying
Dr. Thomas Motz has found himself saying a particular phrase more in the last four months than he has in the past 26 years of being a family practice physician.
The words are: “I can’t fix you.”
It’s not something he learned in medical school, to communicate in four words that a patient has little or no options left to extend his or her life. But it’s an important conversation, and it’s one more local doctors will likely be having as a result of professional development focused on end-of-life care and advance directives. Motz is one of 100 primary care doctors and 188 specialists in the Mesa County Physicians IPA, a professional organization that is examining how to better use conversations with patients and each other to provide better care and reduce expensive, unnecessary treatments.
Back when Motz and other doctors of his generation received their formal training, they were taught to explore every avenue, no matter the financial or emotional cost, to keep someone alive.
After years of practice, some doctors have experienced situations where keeping a patient alive did more harm than good in the end. Other times, expensive, painful tests or procedures did nothing to extend a life, but degraded the quality of the remainder of that patient’s time left on Earth.
As part of their study on how to better serve patients, physicians in the group read Atul Gawande’s book, “Being Mortal.” Gawande, a surgeon who wrote about his experience with patients and his own father at the end of their lives, ponders a new way of looking at living fully and giving patients a sense of control over their health and a feeling of relief by prioritizing how they want to spend their remaining days.
Ultimately, he calls for a change in philosophy about medicine’s priorities. Rather than fighting death at any cost, Gawande argued that doctors should have a different purpose: to make sure patients understand what is going on with their health and take the time to discover what really matters to them, well before the end, to help them have a good quality of life.
Mesa County doctors talked about Gawande’s questions he recommended for initiating difficult discussions with patients and families, as well as how they can incorporate his ideas into their practices.
In these book discussions, recurring themes surfaced. Doctors discussed how they are often caught in the middle of hard decisions when patients and family members might not want the same thing. They also talked about how they can better communicate across specialties to address the bigger picture of a patient’s health. They discussed scenarios where one specialist might give patients hope when, overall, the big picture is that the patient should prepare for the end. It’s hard for patients to receive these mixed messages in a stressful time where they’re grasping for any chance, doctors said.
They also discussed how starting these conversations is difficult, but simply saying, “I’m worried about you,” can be enough to open the door and let a patient know they’re concerned and they eventually need to think about what they’re willing to endure to stay alive — whether that’s being on a ventilator, a feeding tube or other methods.
One of the biggest takeaways physicians discussed was a simple one — the need to discuss what their patients live for and find important, and then being realistic about what they can do to help that patient have their best remaining days.
“What’s the reality for their end of days?” asked Motz, of Western Valley Family Practice. Sometimes this is as simple as asking if they have a last wish or something they’ve been planning on accomplishing before they die. “I’ve had patients that say, ‘I’m afraid to go on the cruise because something might happen,’ and at some point, you have to say, ‘Do you want to die going and doing something or do you want to die sitting in your recliner watching Fox News?’”
Motz recalls one patient who surprised him with how simple her last request was. The woman was in her 80s, in the intensive care unit, with very poor lung function and was not going to live much longer.
“I told her what was going on and I said, ‘Do you understand what I’m telling you?’”
She said, “You’re telling me I’m dying.”
Motz asked her if she had one last wish and she said, “Shrimp from Red Lobster.”
It was a simple request to fulfill, and there was no need to keep her hooked up to machines in the hospital to prolong her life, since there was no chance of recovery and she was content with receiving her wish.
Motz also said there’s a need for patients to understand what methods used for extending life really entail — CPR isn’t like it is on TV, especially when it’s performed on a frail, elderly person who has compromised health.
“I often tell patients, there are things in life that are worse than death,” Motz said, speaking from his experience both as a doctor and from having his fathers and sisters pass away. He said it’s important for patients to be open to discussing the reality of their health with their health care providers and their families, and to make their wishes known before it’s too late.
“We need to have those conversations,” he said. “This is obviously a two-way street, don’t be afraid to bring it up, don’t be afraid to ask questions.”