Thursday, April 10, 2014

Lets Talk About Death.....

Death is inevitable. In my work as an internist in Southern California, taking care of patients in the hospital, I see it often. Sometimes, in my darker moods, I joke just a tad sarcastically, with my team of trainees, reminding them that in So Cal, no one ever dies. This is in the context of memorably rare instances of conversations in the flavor of  "Do everything" and  "I'm waiting for a miracle to happen for my loved one ". Now, I may sound flippant but it is not my intention. It is frustrating to see patients and family members suffer from over treatment, sometimes due to over ambitious physicians care and sometimes due to misunderstanding and overestimating the role of Medicine.

Recently, I heard Dr. Paul Farmer talk about " stupid death"  which he explained as a death that ought not to have happened. When a person dies, usually in a resource poor setting, due to a health condition which would be treatable if they had got the right health care at the right time....that is a stupid death. He talked about how a woman working for his organisation in Haiti, died during pregnancy and that is an example of stupid death- one that is preventable and should never have happened, when it happened.

As a physician, it is my duty to prevent this sort of a death. All my training, my medical reading, my professional obligation is to prevent " stupid death". But what about the other extreme. I read the NYT piece "A 'Code Death' for Dying Patients" by Jessica Nutik Zitter, MD who is a rare breed of physician- one who is board certified in critical care medicine and in palliative care which is often, mistakenly seen as a do-everything versus do-nothing specialty. In this piece she talks about how it is important to be aware of impending death during a patient's illness and then participate in a 'code death' which is palliation at the time of death. This is an important article which should inform our care of patients.

We, as a society and both patients and doctors, need to get comfortable with talking about death, planning for death, just as we do for life. We need to talk to our patients about advance directives, POLSTs and MOLSTs, what they and their family members can expect at the end of life. Whenever we can, we need to prevent stupid death but in case of the good death, the inevitable  death, we should not prolong suffering but simply allay it.