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.   

Cost of Care

We had Chris Moriates come and talk at our grand rounds about cost of care and the need for physicians not to do financial harm in course of caring for our patients. Briefly, he called on the need to be mindful about what we do to patients and think about all our actions.


As I work in our inpatient unit, I have been thinking about what we do in health care and how factor in cost in daily work. Traditionally, costs have been in the domain of health economics and abstruse disciplines that we rarely think of while working with patients. Most patients, however are aware of co-pays, medication prices, ambulance charges and assorted deductibles. Even the ACP ( American College of Physicians) has said in its ethics  manual that equity and cost effectiveness is an important consideration in health care.


These are all meta considerations which can be best done when we consider the whole population even as we treat the individual patient. During bedside rounds, I've been trying to question every investigation we do on our patients by asking why are we doing this test? Is this the best way to get the information we need to care for our patient? Will this test change management? This mindful approach helps us cut down unnecessary testing and is my way of doing "slow medicine" in the hospital. Talk before testing, works for me.

At the end of life...

Even in Southern California, people die. They may die thinner and prettier, but die they do. As I see my patients on rounds, in the hospital, I am frequently thinking the thought- memento mori -remember you must die- and so, the living has to be worthwhile; Life has to count for something.

Often, when I treat sick patients, especially those with cancers who are now on third-, fourth line chemotherapy when I'm broaching end of life care in preparation for CPR discussions and Palliative or Hospice care; they are surprised when I tell them, ever so gently, that the end is near. Sometimes, it is because the Oncologist is not comfortable discussing end of life issues or they have bought into the illusion of fighting  to the end. Sometimes, patients are not listening or they have fixated onto a remark made by another doctor, trainee or nurse.

I'm convinced that as a society we just need to get more comfortable talking about these morbid issues. We need to talk death at the dinner table, at the hospital, at the clinic and anywhere else we need to. Doctors and patients, in my opinion, are like ostriches that pretend that if we hide our head in the sand, Death will not come for us.