How Doctors Die

It’s Not Like the Rest of Us, But It Should Be

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

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. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

*Photo courtesy of patrick.ward04.

  • To die with dignity is to live with dignity.  It’s at the end where I measure what my life is about.  If I die in peace, then I have lived in peace.

  • What a marvelous article, I regret that I’m coming to it so late.  Imagine if the message of this article, that death is not always the worst case scenario, were to permeiate all the stratas of our society.  What if we were honest with one another about 

    death being a
    universal biological fact of life, part of the round of nature.  What if we talked about the end of life as we do its beginning — a
    necessary part of what it means to be human. 
    Everything that we value about life and living — its novelties,
    challenges, opportunities for development — would be impossible without death
    as the defining boundary of our lives.

    Living a good death
    begins the moment we accept our mortality as part of who we are.  The end of life can be a time
    of extraordinary alertness, concentration, and emotional intensity.  It’s possible to use the natural intensity
    and emotion of this final season of life to make it the culminating stage of
    our personal growth.

    If we were able to pass this message on to our patients and clients, we would all become pioneers of a new
    standard of a good death that others could emulate.  Healing and helping professionals are in a unique position to help the rest
    of society desensitize death and dying. 

    Thank you, Dr Murray, for helping break open this conversation.


  • Wow, you are a genius.

  • Most people that demand “everything” for a 90 plus year old have guilt about how they treated that person or live their own lives.  It’s torment for the elderly patient and massively costly for the rest of society to pay millions for their guilt. 

  • Jake Witmer

    This article is a good look at the hypocrisy of the medical establishment.  Due to space and time constraints, it barely scratches the surface of government-protected medical cartel’s destructive hypocrisy and murderous tyranny.  Where do I start? Propranalol?  Stevia? Banning and regulating out of practice Stephen Badylak’s regenerative medicine techniques?  Etc…

  • William Hommel

    Here’s a doctor dying with Parkinson’s Disease, and all he can focus on is helping others while he still can.  (Google this title)
    “Hope for the Violently Aggressive Child” 

  • subra thana

    a great article  worth circulating 

  • Owen Nohn

    why are coffin lids nailed down?

    So oncologists will stop chemo

  • fantastic.

  • Matthew Romagnoli

    I’d follow up on the incompetent nurse who reported you. But much agreed, as a medic who does a lot of “life saving” procedure while ruining you kitchen, people need a plan for their end of life and wishes expressed. the system also needs to change a bit as well.

  • AlanMacD

    The whole point of this article is not about choice but is written to make you feel guilty for choosing to try to beat a terminal illness. It is part of preparing the battleground for limiting your freedom to choose the type of care you want. Dr. Murray first appeals the authority of doctors and then calls out as role models those who choose not to fight and incur medical costs. Doctors know better than you and this article’s agenda just happens to line up with the goals of Obamacare – limiting your choices to reduce the cost of medical care. “You must be stupid, selfish, and evil to fight for your life” is the message. Thank you, Dr. Murray. Without your guidance my aunt would not have seen her grandkids be born let alone seem them turn 8 and 6 and she is still doing fine. 

    • Mickey_disqus

      ” to make you feel guilty for choosing to try to beat a terminal illness”

      Clue’s in the name – TERMINAL illness. If it’s terminal, it can’t be beaten.

      • AlanMacD

        Wow – I *never* knew that, Mickey! Life is terminal too, do you know that?. See the example I gave of my aunt, just one example. She was diagnosed with a terminal illness, given less than a year, and is still with us 9 years later.

    • You have to have a trusting relationship ( which takes time and periodic patient-doctor interaction) with a doctor with good judgement so he can advise you and separate the grain from the chaff. That is the only way to figuring out if you have a “treatable” late stage disease or not.

  • Well that was pretty damned sobering. Thanks for writing this.

  • JasonEC

    This is an excellent article and one which I think points out some interesting topics. It would be great if more people could read this and gain “understanding” of the process of death. The worst things I see in my job as a hospitalist are almost never illnesses or injury. It’s the way families treat each other in that time period around death.

    And it goes both ways. Families put their beloved patient through a ton of suffering by prolonging things. Often it is the result of guilt-directed thinking. But patients do it to their families by not discussing the issue consistently, thus forcing the family to make that decision which isn’t informed by the patient’s actual wishes. Physicians are aware of this and prepare themselves and their families so there is none of that in that time they have left. If only more patients and families had that wisdom.

  • dbg

    this was quite beautiful. thanks for writing this.

  • This is Liberal Bluff

    I strongly disagree!

    The value of a human life seems to be clearly underestimated in this article, i will live every minute and a second of a smiling family near your bed is so precious that it’s worth every heartbeat.

    The attempt to bring brutal life ending care is so bold that i had to publicly disagree!

    • Memegalt2012

      sounds like they are trying to get us ready for Obamacare.

    • backtonature

      Except, apparently you believe the human involved should not be entitled to an opinion. I applaud the doctor for controlling his own care and encourage others to do likewise in similar situations.

    • BonnieB23


      ‘This is Liberal Bluff”.
      What sort of human being are you? Do you really feel that you have the right to dictate when others die even though that patient him or herself wants to leave this world?

      If you believe life is so precious, by all means stay in the game. But, there are others out there who really mean it when they say “Do not resuscitate!” You clearly have not seen many people die in terrible pain. Or sometimes it is not really TERRIBLE pain but a complete lack of quality of life, and dignity with no hope of ever becoming whole again.
      As so many people say, we do not allow our pets to suffer so, why force our loved ones to suffer or to watch US suffer?
      Personally, I do not fear death and do not understand the tenacious grip some people have on life. Death is the next great adventure. Welcome it when it is time and stop doing “heroic” but gruesome, things to put off dying.

  • Ramesh Kumaran

    I have saved my mother with CPR who was terminally ill because of terminal economic crunch.A gangrene toe with hyperglycemic emergency and sepsis.This may not be the cases that u are discussing,but I just thought I would join in.On two occassions, due to fragile DM,She would suddenly slip into hypoglycemia and coma.

  • Liam

    This article has some points but I think unfortunately its grasping a bit too far. Yes the system is not always perfect and it at times leaves us doctors with a bitter taste in our mouths when returning home from a buisy on call or operating days, despite having done everything as it “should be done”. You should not forget however, how we make progress in modern medicine…it can be a sad result for some but a lifesaver for many others later on. I realize this is not a politically correct point if view but maybe closest to the truth…we should not accept “collateral damage” in our practice but thats how it is. Very little is made in theory…the bulk is trial and error almost so to speak…as bizarre it might seem.

  • Thanks for saying what most of us in healthcare already know. Now if only we could get the conversation onto a national level. I helped my friend’s husband with at home hospice (inop lung ca stage iv) & there were issues on all sides–his oncologist was miffed & hospice md we never met but the patient felt abandoned after all the chemo, radiation and draining of fluid from his lungs his oncologist just disappeared, even no reply when Tom emailed him. Very disappointing. Then I was shocked that hospice provided sublingual oral pain meds–by the gallon, delivered to doorstep–+ duragesic patches, but I’d been prepared to manage his IV and a morphine drip; we met the hospice RN once then it was nursing assistants who were mainly good but his pain was difficult to manage with the liquid so I was trying to get better pain mgmt daily, w/o success. This is supposed to be a big part of hospice! They told me to give him more more but he could only swallow so much, then couldn’t swallow at all. I hoped the morphine and ativan that pooled in his cheek would somehow absorb. It was very traumatic for his wife, also a nurse, and me to know he was in such pain. They repeatedly said “oh you’re a hospital nurse, you guys always want IV’s”— well Yes we do! For adequate pain mgmt! we weren’t giving him food or fluids but he really needed pain relief, I didn’t sleep the last 2 days, trying to reposition him (he was 6’4, 60yrs old very athletic, non-smoker) and suspect he died earlier because one night he got in an odd position trying to avoid the tumor and his airway looked cramped—, o2 sat 55. it was 6 hrs later he died. Then his wife, my friend, fell apart & hospice decamped, asked her “do you want to see/ talk to someone?” and took her stunned “no” for a final answer. I had to phone the Onc Services at UCLA and call in favors to get them to call her, get her in & help her out. She really hadn’t been able to believe he would die, she later said. I’m relaying this (as I did to my PCP) to say that all Hospices are not equal, and you, the patient are the consumer–ask questions, esp about pain relief. We had mountains of meds left over that were useless for Tom, expensive meds. So there’s yet another component to add to the AD. I want an IV, not for fluids but for pain control and agitation mgmt. I was astonished that in L.A. a hospice service could be so bad. Tom died in a lot of pain, his biggest fear –& I talked him out of suicide, saying how effective hospice and morphine/ativan are, it still upsets me 3yrs later. These things need to be discussed and stop the hysterics as if a young healthy person will be denied care (though that already happens by insurance companies.) and realize we’re talking about very ill people with serious disease and poor prognoses. What do we want to put them through? We in health care know what aggressive care can entail in a fragile or compromised patient and don’t want it for ourselves or family. That is the Truth. Republicans can be glad that my boomer generation is more for quality of life over quantity and is not going to cost Medicare much. We also don’t believe doctors know everything like our parents did so don’t blindly follow….
    Thanks for excellent post! Please write more, including in NYTimes.

  • guy deck

    I came to these same conclusions years ago. If there is no quality of life, let me go quietly.

  • Excellent article, thank you.

  • My mother “Coded” after receiving a dose of Epinephrine for a severe allergic reaction. She was down for 57 minutes, was defibrillated 10 times and the CPR never stopped, until she had a pulse.

    She was talking to me less than 13 hours later. Her throat was sore from the intubation, her chest was sore and bruised but she suffered no broken ribs. CPR when done properly does NOT guarantee broken ribs.

    A local cit firefighter coded on the scene of a fire. His crew worked him right there on the fire scene. Poor bastard didn’t have NO CODE stamped on him anywhere and now he’s back on the job fighting fires.

    As a first responder who has arrived on scene to a family performing CPR on their father in the front yard and then worked that man until he got a pulse back I know that the system can and does work.

    CPR and ACLS has a low survival rate, this is true.

    But doing nothing has a 100% fatality rate.

    I have met the cancer survivors who endured weeks of chemo and a miserable existence only to die a short time later. I also volunteer Thursday nights at a rural rescue squad with a cancer survivor. She endured weeks of chemo and led a miserable existence just so she could survive. What a silly woman for being willing to suffer to survive.

    It’s a good thing none of these people read this article before they got sick or they wouldn’t of known how horrible it is to endure treatment just to survive.

    This article is nothing short of irresponsible in it’s representation of modern medicine. The author, and other burnt out providers who agree with him, should consider other lines of work.

    • xnlover

      Life also has “a 100% fatality rate.” And for every “success story” of a survivor, a story of needless pain and suffering can be cited to call it into question. Dr. Murray’s point is that the questions of end-of-life care need to be considered and answered by each person before the answers are needed, not when the person has collapsed on the front lawn or is being intubated in the ambulance or rushed into surgery at the hospital.

  • jacqueline berry

    I loved your essay I am in the business of medicine formerly pharma medica equipment and I went thru an awful experience when my dad faced mortality primary biliary cirrhosis and stage 4 salivary cancer gave him radiation no surgery and he really suffered the last month because I kept trying interventions based on some doctors recommendations and my own he caught mrsa couldn’t eat I have had a really hard time accepting this but what amazed me if how physicians wouldn’t level with me….one did and I ignored his advice hoping the other doctors offering radiation could give him another year….big mistake and I am a social worker also we really as a society need to come to terms with this….many doctors I knew from my job told me exactly what you have said that they wouldn’t put themselves thru some of the treatments they offer their patients thanks for writing is made me feel so much better

  • Beth

    Thank you! I work in a hospital and cancer center and this issue has been tugging at my heart for quite some time. It is very difficult to see what people are going thru during the last 6 months of their life. I

  • I have a dear friend who passed before 50, diagnosed with a virulent cancer that took her within four months of diagnosis. She had seen her mother fight cancer four times (four different things!) and finally decide the last time was enough of being made sick, and etc. So that is what my friend did.

    Her and her husband had time to do a couple of trips and family visits, then she just kind of drowsed her way out. They had offered chemo, but as she put it, ‘it might buy me a couple of months but who wants to live bald and puking? Especially if it will only buy a couple of months?”

    She was a sweet, kind, gentle person. I will miss her forever.

  • Edward Omron

    “The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs… What it buys is misery we would not inflict
    on a terrorist. ”

    Dear Dr. Murray,

    The above statements illustrate case and point why family physicians are precluded from practicing or participating in the medical decision process in most modern day ICU’s in the United States.You have professionally maligned and insulted the field of critical care medicine and misinformed your audience. You misrepresent and confuse our excellent ICU care with the ethical questions of informed medical decision making, advance directives, patient autonomy, and rationing of health care resources. We as INTENSIVE CARE PHYSICIANS assault NO ONE. We manage pain, anxiety, and “misery” and ameliorate it with the best medicines 2013 care can provide. Intensivist directed ICU care is very expensive but very powerful. WE can and frequently do recover patients from the brink of death to full recovery. We do not discriminate between children, mothers, fathers, and grandparents. If there is an advanced directive in place, we limit our interventions. If care is futile, we rally the family and discuss the reality openly without reservation. The human body is a wonderfully complex, adaptive and restorative system. Our goal is to give human life every chance possible but at the same time we allow natural death to occur. To state our goal is financial is asinine and shameful. Your conception of ICU care is generation old out of sync with current reality.

    • bhoven

      Dear dr. Omron, as a colleague in Intensive Care Medicine I feel that you completely miss the gist of the massage Ken Murray wants to get across. You cannot state that we never miss an opportunity to not act while we could in a hopeless case. I have been a consultant doctor in IC Medicine for 25 years so I feel qualified to have an opinion in this matter and I am very much aware of circumstances in which I failed the patient in favor of pressure from family and other relatives. We can do a lot, but the real art of medicine is when to apply to right care for the right patient.
      Kind regards,
      Ben van der Hoven

      • Edward Omron

        Dear Dr Hoven,
        I appreciate your commentary but mass media medical misinformation needs to be thoroughly and unambiguously challenged whenever encountered. Dr Murray’s commentary, I am sure came, from good intentions but he crossed the line when he used words to cut deeper than a scalpel. His commentary was inflammatory and meant to illicit some kind of emotional disgust at current day critical care medicine. He used and abused my specialty to advance his own ethical and political agenda. I reject that commentary for that sake alone.

        Kind Regards
        Edward Omron MD, MPH, FCCP

        • xnlover

          Dear Dr. Omron,
          As a layperson who knows people whose specialty is critical care, I did not read any of Dr. Murray’s article as maligning those in your practice. He was referring from the outset of his article to persons whose deaths were imminent and who chose not to employ the skills of those of you who work in critical care to keep them from dying, not those who were in generally good health who had experienced a medical emergency, the recovery from which would restore them to an otherwise healthy and fruitful life. You do important and necessary work in your field, and yet there is a time when the type of services you provide are simply not in the best interests of the patient. Dr. Murray does not seem to me to be saying that no one should ever be treated in ICU, but that the focus of care should be the definition of a meaningful life that the patient him- or herself has defined and made clear to her or his loved ones and physician prior to the point in life at which such information might be needed. That, and not “what is possible medically,” should be the final measure of “good treatment” for everyone.
          Best regards,
          Douglas Asbury

    • jdistefa2 .

      Whoa, relax fella. ER doc here. I think you completely missed the point of the article. Turn your ego and defenses down and read it again with a more open mind.

  • john3932

    Your Statement “It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.” should have been supported with data that backs up the assertion. As it is, I can only take this as your opinion.

    • nashvillechick

      I worked for 7 years as an inpatient hospice nurse and there were very few among my co-workers and other colleagues (I actually can’t think of one) who would not agree with Dr. Murray, myself included. I know nurses with DNR tattooed on their chests. We aren’t kidding when we say that we don’t want to SUFFER with unnecessary, futile treatments at the end of our days.

  • Phip Nosiw

    Dr. Murray
    I am stage 4, metastasized, palliative care prostate cancer. I dc’d chemo 6 mo ago, and prognosis is 18 mo /c further treatment. I know whereof you speak; it has been a very good life, and I will not end it whimpering semiconsciously in a hospital room if I can prevent it. There are those that prize length of life over the quality of that life. I am not in that crowd.
    Staring the Reaper in the face, and not speaking hypothetically, I will live as well as possible for as long as possible. When the bad days substantially outnumber the good days, I’ll initiate plan B and leave with as little fanfare as possible.

    Jack London perhaps said it best; ” I will live the time I have. I will not spend my days prolonging my years.”

  • J. Ammons

    Dear Dr. Murray,
    I am an ICU nurse and can honestly say that I have never responded to information post such as this. However I must commend you for writing this as you have “hit the nail on the head”. I get so frustrated with providing futile care that is being dictated by an uninformed family. I feel as though I am aiding in a form of cruel torture at times. I am very honest about death and dying with patients and families and this gives me the strength to speak with family members about the limitations of medicine. I frequently say to families “ask any medical personnel where they intend to die and almost everyone will say in the peace of my own home”. I think it is a sad society that we live in that allows such treatment of people to occur largely out of a failure of communication about the true limitation of medicine. I believe in a perfect world, every healthcare provider would treat every patient the same as they would want to be treated if the roles were reversed. I am sadly aware that we are a long way away from being a perfect world.

    • nashvillechick

      Amen to that! I’m also an RN and can’t count the number of times that I’ve watched patients receive profoundly costly and futile treatments, only to be sent over to hospice when there was nothing more that could be done to keep the heart beating. It’s appalling.

  • backtonature

    Wrong article.

  • backtonature

    If the patient wants the treatment, she should have it. But it sounds like the family pushed it. If that is the case, end of life wishes should be established in writing and those should be respected.

  • Good article, thanks for sharing this informations

  • Excellent article.

  • Chris

    My 43 year old son is receiving palliative chemotherapy for terminal bowel cancer. Seeing him slowly deteriorate is really horrible.I hate seeing him feeling so sick and fatigued. I know that if it were me, I would NOT have any medical intervention to extend my life. But my son’s circumstances are different. He just doesn’t want to leave his lovely wife and young children. Every day he has with them is precious. It was my son’s choice to do everything possible to extend his life for as long as possible but I’m sure that if he was my age with his children all grown up, things would be different.

    • Stonejaw

      Sorry to read about your son. It must be very difficult for both you and his family.

      Very unstandable that at 43 your son “wants to do everything possible to extend his life for as long as possible.” However, I think that is true for most everyone as the self-preservation instinct is usually pretty strong. Hopefully, your son has made a good informed choice. I am confused with the concept that he is receiving palliative care and “It was my son’s choice to do everything possible to extend his life for as long as possible.” The goal of palliative care is to provide patients with relief from symptoms, pain and stress of a serious illness and not to do anything that will provide life prolonging care.

      I quote from the article above “Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures.”

      I wish you and you family strength during this most difficult of times.

      • Chris

        Sorry, maybe “palliative chemotherapy” wasn’t the right term.
        I thought that’s what my son called it. I’m just a mother. I thought that palliative chemotherapy meant that although there is no cure, it is intended to prolong his life and keep his cancer under control as long as possible. His cancer is widespread but the wonderful news is that he’s now 44 and healthier than he was when I first wrote 7 months ago thanks to the wonderful care of the staff at Cancer Care centre at Concord Hospital NSW. When he was first diagnosed with stage 4 terminal bowel cancer 16 months ago, before any treatment, he was very, very ill and we didn’t expect him to last very long. No one expected him to make his 44th birthday but we’re “over the moon” that he has. In the beginning, I couldn’t understand why he chose chemotherapy to extend his life. I was under the
        impression that with chemo, although he’d live a little longer, he’d be very sick and have no quality of life until he finally died. But that’s not really the case. Although chemotherapy isn’t
        fun, he DOES have quality of life particularly on his “off chemo weeks” and it’s given him more time.

        • Chris Huddle

          That’s awesome! I have three kids so I understand his decision perfectly. Best of luck to you and your son. – Chris

          • Chris

            My son passed away on 8th January 2015. He was told right from the beginning that his cancer was incurable because he had tumours all throughout his liver as well as his bowel and lungs. He just didn’t want to leave his wife and children so he fought with all his might. After watching my son suffer so much, I know that if I was told I had an incurable illness I would NOT fight like he did. But it’s harder to accept death when you are 44 and have young children.

        • Chris

          Just an update on my son: He has been receiving fortnightly chemotherapy without at break since he was first diagnosed with terminal stage 4 Bowel Cancer in March last year. (you call it Colon Cancer in the US.)The latest two rounds of his chemo have not been working and his tumours have grown so now he’s very weak and can hardly stand. He looks like a walking skeleton and he just wants to sleep. So now his Oncologist has just put him back on Folfox which is making him very ill with lots of terrible side effects. Folfox picked him up when he was first diagnosed but we don’t know yet is it’s working this time. It is just agonising watching my son deteriorate. I feel that giving my son Folfox on his very frail, very sick, very weak body when his doctors have made it very clear that he is close to the end just doesn’t make sense to me, but my son and his wife are determined to fight to the end. I personally would prefer to see him get off the chemotherapy which seems to me to be futile over-treatment and instead just concentrate on making him as comfortable as possible. I can well understand why doctors die differently.

      • nashvillechick

        To qualify for hospice care, one must have a terminal diagnosis with a prognosis of 6 months or less. Treatments like chemo, radiation, and dialysis are generally only approved if they contribute toward the patient’s comfort level or quality of life. For instance, radiation may shrink malignant brain or spinal tumors, thereby lessening headaches and nerve pain, even when it can’t stop the cancer.
        Palliative (comfort) care provides symptom relief for people with serious/chronic illnesses, no matter where they are in the disease process. They can receive curative treatments and also qualify for palliative care to help with side effects of treatments (ex: chemo) or just to improve quality of life for a chronically ill person with a greater than 6 month prognosis.
        So hospice and palliative care are similar, but still different. It’s also not uncommon for a person to eventually stop treatment and transition to hospice care only.

    • Patricia Garvin Fox

      Palliative care is quite different from futile care. You make the point, however, about the need for treatment to be individualized.

  • barochallo

    What an excellent article, Dr Murray, thank you for putting into perfect prose, thoughts that must exist in the minds of almost every doctor in the world today.

    I guess that’s where the difference between mundane knowledge and wisdom lies. Knowledge, where one knows everything about the text-book treatment of a patient, and Wisdom, where the physician knows exactly where to use that knowledge. Or better still, where NOT to use that knowledge at all.

    I am an ophthalmologist, not a critical care physician, but in my field too, there are a number of conditions where treatments are offered or pushed down the throat by the ‘system’ to preserve or increase the vision of these patients. And most of us know that these treatment modalities are either cosmetic, temporary, downright ineffective, or not required at all, while increaing the suffering of the patient. And with the common denominator, frightfully expensive…

    In these circumstances, there will always be the voices of those who will argue about such thoughts throttling scientific progress, medical advancement etc. But they fail to realize that a balance is never achieved. The cost to the patient in terms of money and suffering is always sacrificed at the alter of scientific progress in the field of medicine.

    Your article also importantly suggests the possibility of a holistic ‘treatment’ of these patients, who can live the remaining days of their lives doing the things they always wanted enjoyed, but never had the time or favourable circumstances to. Like the characters played by Morgan Freeman and Jack Nicholson in the bucket list.

    Thank you again for this eye-opener article. It made my day…

  • Ikechukwu Azuonye

    Good article, but very limited in its scope. Medical doctors do not die only of diseases that take months or years to take their lives. Medical doctors also die of the effects of road traffic and other accidents, acute illnesses that kill them in a matter of hours or days, manslaughter, murder, accidental self-poisoning with alcohol or illicit drugs, single-person suicide or suicide pacts.

    • prof_emeritus

      I cannot figure out your point. Try reading it again.

  • veryedumacated

    Interesting eye opener. Reinforces my thinking about the knowledge and experience of medical doctors versus everyone else that has their own medical opinions on what we should eat, drink, and pill pop.

  • srhendra

    Good article, but very limited in its scope. Medical doctors do not die only of diseases that take months or years to take their lives. Medical doctors also die of the effects of road traffic and other accidents, acute illnesses that kill them in a matter of hours or days, manslaughter, murder, accidental self-poisoning with alcohol or illicit drugs, single-person suicide or suicide pacts

    cara terbaru, kunci jawaban tebak gambar, cara terindah

    • DrH

      I think you missed the point of the article. When doctors are faced with chronic terminal illnesses most of them choose to forgo full resuscitative measures which would prolong their suffering. The fact that other causes of death affect doctors too is obvious and goes without saying,

  • Kevin Abourezk

    My sister died last month after suffering a massive heart attack that left her clinically “dead” for 15 minutes before doctors could revive her. She was brain dead, and we all knew it. But it’s so hard to let go when you don’t have definitive information. We waited 36 hours for a brain scan to tell us she was brain dead before we pulled her off life support. I know now she died during those 15 minutes and wish we could have accepted it then.

    Thank you for your article. I plan to try to have the courage to face my death with dignity and seek out quality rather than quantity of life.

  • utardia

    I am a nurse who works at a local VA center and I am assigned to the “locked” dementia unit. It saddens me on a daily basis to see these Veterans suffer with procedures that “prolong” their lives. Men who fought for our freedom and are sent out to the ER over and over at the ages of 75,80,90 + years because their families refuse to sign a DNR and they are “Full Codes”. Saddest is when they can no longer swallow and usually aspirate and we have to send them out. 100% return with feeding tubes because their families are not ready to let go. We continue to do our jobs and care for them as if they are our own parents. When their death does come, our staff is quietly rejoicing for them because we know that they’ll be free of the suffering.

  • Ana H.

    My uncle is a noted physician in his late 80’s in pretty good health, but he keeps a regular prescription of some medication that he could easily take by himself if he felt the time had come. I think it says a great deal when a doctor can choose to end his life fairly comfortably but others cannot.

    I contrast that with my cousin who had advanced Alzheimer’s. She was delusional and barely responsive, and the head nurse at the Memory Care Unit fought me because I wanted to discontinue my aunt’s high blood pressure and clot-prevention medication. She was terminal, and 89 years old. I wanted her to continue on all comfort-inducing meds, including Lasix (fluid in your lungs is very uncomfortable) and Ativan (anxiety/agitation). She was dying, she could barely remember her own name, she wouldn’t eat, she stood in her room and would open and close a dresser drawer over and over again because she was so lost, and they are fighting me over letting her go – which was in her living will.

    Ultimately, they kicked her out of the MCU because she was non-compliant (of course she was, she had advanced Alzheimers!). I moved her into a full-care nursing facility. They respected the choices I made on her behalf. They pretended that she was helping them plan events and so they would ask for her help with “tasting menus” and “decorating advice” – all to get her out of her room and eating. She was happy and “busy” with her work and thought she was living there to help them out. One night I got a call that she had a fever and they wanted to take her to the ER to be checked out. I said ok, and headed to the hospital. 15 minutes later, the nurse called, crying. My cousin had gone into cardiac arrest and pursuant to her wishes, they held her hand and let her go.

    I’m now the primary caretaker for my father, who has vascular dementia and Alzheimer’s. My grandmother was essentially in limited consciousness the last six months of her life because of Alzheimer’s. There’s a high likelihood I will follow in their footsteps.

    Respecting life also means respecting death and the choices our families make when we cannot make them. I hope that if I follow my family path into Alzheimer’s, my husband or kids will have the strength to let me go, and if I linger as my grandmother did, that they will have the ability to make me a delightful gin martini with a little extra on the side, so that I can die with dignity instead of live like the undead.

    • pandora delphy

      What you’ve written here is both sad and beautiful. Thank you for your courage. I wish you all the best.

  • nashvillechick

    Yes, that patient would qualify for palliative care, and then for hospice care when the doctors certified that he/she was not expected to live more than 6 months. This is not an uncommon scenario.

  • jdistefa2 .

    Excellent, excellent article. You captured the humanity, more than occasional inhumanity, uncertainty, and various pressures around end of life care perfectly. I have read this frequently and pass it on to others who also practice acute/critical care medicine. Well done, thank you for writing it.

  • pandora delphy

    Thank you for writing this amazing article. Dignified and filled with humanity–the way the healthcare profession should be but all too often isn’t.

  • Bernacks

    My husband Mike passed away this past March of 2014 from pancreatic cancer. Towards the end of his life he saved this article and asked me to read it when I am able to. I finally got the will to read it and well, 5 months after his passingI realized he did it exactly on his terms. He was at home the the entire time, many of his friends and family had visited him many time from CA, NY & PA. With his hospital bed next to my bed we were able to hold hands and even cuddle at times. Then finally at 1:30 am I suddenly woke up and felt him, his hand was still warm but I could not hear him breathing anymore. I had a friend who had been staying with me for the past two days (who happens to be a RN) and she told me that he did pass. It was very surreal, but I feel like he passed in his sleep so that people were not hanging over him and he gently kissed me good bye (at 1:30am) which is what woke me up. To me it was the most beautiful passing for this ugly cancer. Thank you for letting me vent and continue on this healing journey.

  • fattykim

    The Opportunity Cost of Futile Treatment in the ICU

  • Black JEM

    Saw this reprint in Time Magazine.

    Similar story – Stage 4 colon cancer, metastasized in the liver, in my wife. Treated it aggressively to start but got the fateful I’m sorry nothing else we think will work. Our oncologist was up front about additional therapies we could try, referrals that he would be willing to make, but that in his opinion that would mean hospitalization, tubes and procedures and dying in the hospital. He recommended hospice, thought we should really strongly consider quality of life for what was remaining. We went that route. It ended a little more quickly than even the doctors predicted, but she was home, among family and friends. She died peacefully at home – no tubes, minor pain killers, able to eat. I was able to hold her as she passed.
    I highly recommend you listen to what this author has to say.

  • Patricia Garvin Fox

    In the MICU of the world renowned cancer hospital where I worked for many years I saw many examples of futile care but one is branded into my memory.

    The patient had end stage multiple myeloma and I don’t remember the complication that landed her in intensive care. Given her advanced disease it made little sense but policy had deemed anyone on a ventilator went to ICU.

    She was a slight woman to begin with and was now painfully wasted. She had not had an appetite for some time and what nutrition she did take in seemed to feed only the widespread malignancy.

    One day she coded and her family despite her prognosis had refused no code status and she had gone along with them. My hands and my ears still recall the feel and sound of her ribs and sternum fracturing with compressions. We “saved her with this horrifying CPR.

    A couple of days later I happened to be in the unit and her the crack when her humerus snapped from the simple act of her nurse bathing her. Putting a tourniquet on to start an IV was hard, I just prayed I wouldn’t break her other arm with it. She was still aware at this point.

    Soon, another crash and another successful resuscitation. The only good part was that she was comatose from then on and didn’t seem to suffer from her fractures and bone pain. The family continued to insist that we “do everything possible.” The problem was that we already had and it failed, all we had was prolonging her dying.

    She was on high doses of pressors and her extremities began to show tissue death from the miserable circulation. The family never seemed to grasp that watching her fingers and toes die was actually part of doing everything.

    There were a couple of additional codes. Her primary nurse, a woman with years of experience, almost quit nursing the day a large part of the woman’s gangrenous tongue simply fell off during oral care.

    The family never budged and at that time there was no futile care policy in the medical center. I was not present for the final code when our patient finally managed to escaped her ravaged body. It was understood that the last code was a “slow ten count code.” For those who don’t know, this was basically a deliberately slow response basically to let a patient die naturally before a pointless resuscitation attempt. Never official, these codes did sometimes happen.

    Not long after this, a futility of care policy was implemented by mutual agreement of the med center institutions. In most cases, it prevented the horror show of cruelty by codes. I think evey single one of us who had any part in this uncaring care had advance directives after that and made wishes clear to our next of kin.

    And yet we still see the occasional case where a family demands futile care, even if a legally dead corpse on life support. Or rather death support, to my mind. I think we still have a great need for ways to educate patients and families about realities no one wants to face but should if only in the name of mercy and justice.

    That patient had excellent insurance, by the way, and those horrifying weeks generated a stupefyingly high bill.

  • Huigh

    I’ll be 70 next month, have chronic AF, don’t know how much longer I’ll be above ground, not too long I hope. Cannot express how hugely relieved and grateful I am to have come across your article. My wife and GP will both receive clear directions about my desire to just go as peacefully as possible when the time comes, I owe the earth my quota of fertiliser 😉

  • Mohandas

    Thank you for depicting the real picture. When a man or woman is sure to die in a few months, it is better that they are allowed to have a peaceful death at home with their loved ones rather than be in horrible hospital environment with hose pipes in the nose and mouth perpetually being fed through a nozzle from a drip bottle. I am 69 and wish that I will be forced into such a situation, but my children (one is a Doctor, Radiologist) and wife may think otherwise and try to prolong my life on ‘life supporting’ devices. Probably if an young man or woman in her prime caught in an accident can be kept in an I c U with the hope that by some miracle( yes, miracle do happen, Doctors also will agree) he or she may come back to life. But even there, case of terminal diseases particularly among senior citizens like me who are beyond their prime, peaceful death is a better option than a miserable last few days in an ICU.
    I remember the beautiful movie ” Bucket List” in which a millionaire and a poor African American porter, both suffering from ailments that will end their life in a few months meet in a hospital owned by the rich man become good friends. They together go on an overseas trip to complete the ‘bucket list’ originally prepared by the porter and added to by the millionaire. “Enjoy life, if you are going to die in a few months, you have done your bit.Let others do the rest” That should be the spirit.

  • Marianne

    Thank you so much for this vulnerable, honest and wonderfully written article. I found it at exactly the right time.

  • Polar Jo

    Beautiful, if an article about death can be beautiful…when I die I want to die like a doctor would …:) A great way to approach this subject with your families as well. Superbly written, reason resounds, so also does sensitivity. Thank You.

  • First_Blush21
  • Marcus Henry Weber

    My grandmother made it to her early nineties, and when she died recently, after a fall in the nursing home, I’m very happy that my whole family was unanimous; no invasive attempts to keep her alive. She had a long life and died with her children and their children around her, and that’s more than most can say.

  • GD

    Well spoken. Death is the exit door through which we all must pass. Needless, costly, and undignified suffering via interventionist medicine does not change that, but the diminishment of the person through the process is painful. Observed 1st hand on my father’s passing, no quality, just lots of suffering & $$.

  • Mihangel apYrs

    I want nothing that the physician wouldn’t want for themself, or for someone they loved enough to allow to go.

    I watched my mother die in an intensive care unit, and my father grieve watching her. I don’t want officious care, nor will I demand it for my husband …

  • Mihangel apYrs

    the point is not to keep alive someone whose quality of life is fading. What would you want to happen to someone you loved enough to let go – drugged, tubed and lingering, or to slip away? It depends on circumstances, and a trust in those treating us that they will choose the best option not the safest. That is part of your duty as a carer, to be able to make those decisions in a way you feel content with.

    Good luck

  • Jennifer

    I would like to know on what planet does someone get 8 months worth of anti-brain swelling drugs for “about $20.” Must have had great insurance.

    • Humuhumu

      no, the medicine is incredibly cheap. Dexamethasone 4 mg. $23 for 100 tabs at Costco

  • Leslie

    Last November my 20 year old son fell from 12′ on to his head. He suffered a traumatic brain injury and never regained consciousness. When he entered the hospital he was given a Glasgow Coma Scale rating of 3. That is on a scale of 3-15. Shortly after hearing the news I was speaking to a neurosurgeon who was asking for permission to do a decompressive craniectomy. He explained that there was a 30% chance that my son, who had elected to be an organ donor as noted on his driver’s license, would die in the operating room and if he survived he would likely never walk again, he would probably not be able to feed himself and he would have poor cognitive function. Then he asked again, “We need to do the surgery right now. Pressure is building in his brain. Do we have your permission?” “Wait, can you tell me again . . .is there something I am not understanding?” I knew a little bit about TBI, I was helping a friend with an event for Craig Hospital, one of the premiere rehabilitation hospitals for TBI in the country. Even for patients with good outcomes a traumatic brain injury can rob the person of their personality. That on top of virtually no motor function I didn’t understand why they would saw into my sons head and violate his body. I asked the doctor what he would do it it was his son, he said he would do the surgery. I said no.
    My son was in another state and with my sister and brother-in-law holding me up and guiding me through the airport and to the hospital I made the 8 hr trip in time to see my son alive. I was so worried about what i would see when I entered the ICU, a head injury sounds like a violent injury, but when I entered his room I was struck by how beautiful he looked. He wasn’t bruised, his body wasn’t violated, his color was good. He didn’t look scary, he looked peaceful. He looked as though he was sleeping. In that room I was able to hold his hand, it was warm, and run my hands through his hair. His hair hadn’t been shaved.I was able to bond with my son in much the same way as I had in a hospital room 20 years before when he was born. When I said goodbye to him I knew that he was at the top of his game, successful in school with a close group of friends. I knew that the last thing he knew was sitting on banister, talking to a high school friend about how far they had come when he lost his balance fell back and that was all. That night I was able and unafraid to leaning over his beautiful strong body to kiss his cheek and say goodnight.
    That I was able to see my son looking the way that he did in the ICU has been a critical part of my ability to cope in the wake of his death. Things would have been much different if they had done the surgery, I have been on the internet and seen the pictures of what a decompressive craniectomy looks like. On the night of my son’s accident when I refused to allow the hospital to take a section of his scull off the doctor followed with another request, could they but a “bolt” into his scull to monitor the pressure. Why would I want to shave his hair and drill a “small” hole in his scull to monitor pressure when we have already decided not to do the surgery to relieve pressure. All I cared about was wether my son was in pain and I was assured he had felt no pain. Another thing that I have thought about was the fact that there was a 30% chance my son would have died in surgery. I can’t imagine what it would have felt like to arrive after he had died to see his scull removed and his body all cut up for the organ donations.
    In the months since his death I have been struggling with why the neurosurgeon would have done the surgery on his son. I have been on the internet everyday searching for something that might have changed my mind. I have consulted with a friend who was deputy chief of surgery and a major emergency room and everything I learned has only served to reinforce my decision but still I am having a hard time letting go of the idea that when asked the doctor said he would do the surgery on his own son.

  • SuzanShinazyRN

    Really? As an ICU RN, I saw more than a few physicians doing everything they could to stay alive, against all odds. I would say this is an individuals choice and all doctors do not think a like.

  • Pete Lindfors

    Thank you, thank you Karen. What Torch got is exactly what I want, when the time comes. Dad.