End of Life - thoughts from an MD

I drive 20 miles - past three other hospital '...

2012-01-29T16:21:33.540-08:00

I drive 20 miles - past three other hospital 'systems' to get to my PCP - who is in a hospital owned practice and has had electronic access with email for several years, and is participating in "Open Notes" (BIDMC in Boston) so that I can review notes from office visits after the visit. We decide in advance what labs, etc to do at a visit, and then can discuss them in detail - and i can see labs, mammogram, etc. as soon as they are posted - sometimes earlier than he does!

I recently came across your blog and have been rea...

2012-01-27T08:04:41.992-08:00

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

Susan

Cure for Sweaty Feet

I have discussed this subject with my vet on more ...

2012-01-07T18:58:49.401-08:00

I have discussed this subject with my vet on more than one occasion. i am a nurse who works with elderly people at home (sometimes also receiving hospice care, often not actively dying.) Fear of death is much less than fear of disability and loss of dignity (control). Our medical system in US does a lousy job of getting folks into hospice care so the focus is on comfort. Even elders who are not actively dying don't want to run around and see a different specialist for every ailment. My vet is great about doing labs and a good exam and maybe an xray, then making an educated guess as to the most likely cause of the problem, and treatment options. My own doc practices this way, and it just makes sense. Life is generally a chronic condition that eventually becomes fatal, for all of us. (or we die young, which is worse).

Boy, has entering hospice caused me to question my...

2011-12-27T22:36:33.242-08:00

Boy, has entering hospice caused me to question my views on this.

I have always believed that euthanasia should be an option and have come to agree with Byock that suicidal ideation during a terminal illness is generally a matter of people being frightened that their symptoms won't be controlled. I have seen this wish diminish as intractable n/v have been stopped, excruciating pain conquered....

Tonight I attended a man with terminal agitation. The family is distraught, he is miserable - hallucinating, crying out - and none of our interventions are working. His death is going to drag on for at least another week. He is suffering. I can't help enough.

I am so sorry for the loss of your friend and companion. At least you could give him the gift of a peaceful release from pain.

I am very sorry for your loss. This was often a to...

2011-12-26T13:48:54.961-08:00

I am very sorry for your loss. This was often a topic of discussion among my family as my mother suffered from cancer. Both my mother and one of our dogs had cancer mets in their bones. When the time finally came, we were able to euthanize Austin (sweet dog), and end his suffering, while mom continued to allow " life" to run it's course.

Merry Christmas & new year! I too have had the...

2011-12-25T06:37:38.235-08:00

Merry Christmas & new year! I too have had the experience of eurhanizing a dog. As a physician myself I am of the opinion that ( in all aspects of medicine ) the primary goal should be thr relief of suffering - both physical and emotional. This does NOT necessarily equate with euthanasia but may of necessity result in death whilst providing relief from suffering. With the mindset and goal of achieving relief from suffering through use of standard methods and always following legally acceptable procedures,, I think that many dilemmas can be resolved with a clear conscience.

I'm sorry for your loss. I am a veterinarian. ...

2011-12-25T05:43:42.688-08:00

I'm sorry for your loss. I am a veterinarian. More than one client has asked me in jocular fashion if I could put THEM to sleep as they have neared the end of their useful chemotherapy or whatever. From their responses when I have declined to do so, I don't think they were all kidding.

I recently came across your site and have been rea...

2011-12-21T00:58:11.154-08:00

I recently came across your site and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

Susan

Cure for Sweaty Feet

Please do use this quotation freely. I hope that ...

2011-12-20T09:26:39.493-08:00

Please do use this quotation freely. I hope that it may help.

I would like to have permission to use this as a q...

2011-12-20T02:13:55.308-08:00

I would like to have permission to use this as a quotation in order to discuss this sensitive subject with my family. I am a health care professional myself who has seen so much sadness around this very subject. I have also seen so much comfort and joy when the matter of death and dying has been openly discussed and provision made. Thanks for posting. LH

I now work in a state that does not utilize the PO...

2011-12-18T21:25:35.990-08:00

I now work in a state that does not utilize the POLST. A pity.

If that time comes, Alli, we will be honored to wa...

2011-12-03T18:55:35.065-08:00

If that time comes, Alli, we will be honored to walk with you on your journey. May you not need us. :)

Many people still have the misconception a Hospice...

2011-11-28T10:49:46.340-08:00

Many people still have the misconception a Hospice is a "House of Death" Mostly due to a lack of information. A few years ago they were planning on opening a Hospice in a very old quiet residential area of my city. The home was perfect. Lovely views, spacious rooms, a peaceful place. You would have thought Dr Kervorkian had planned on moving in. Petitions were distributed signed and the area deemed inappropriate for a Hospice. Eventually they did build in a more commercial area on one of the busier streets that would blend in better. Since there was a funeral home in the proximity. This was in Canada (Ontario)

I am a Breast Cancer patient, I was diagnosed with stage3 grade3 in 2009. Currently in remission. If and when the time comes that I need further care to control pain at the end of my life most definitely Hospice will be my first option. I have lost friends in recent years, the care they received was beyond compare. The patients needs are always first priority. Allowing a patient to do it "Their Way" allows them the dignity of a "good death" What could be better? I do believe there needs to be more information detailing the idea of Hospice Care in the public sector . Misinformation can make the difference in the way a person chooses the end of life. Also to alleviate the myth that there is Dr Death or Nurse Black waiting with a syringe filled with a lethal concoction. Alli...

I agree with Dr. deMaine. My husband past away wit...

2011-11-24T19:43:23.102-08:00

I agree with Dr. deMaine.
My husband past away with stage 4 Colon Cancer and I wish his Dr. had been more honest about the situation. My husband left many unfinished issues and went through a horrible operation that in retrospect I wish he never had.
I really do not appreciate the lack of sincerity
from his Dr.

Erica

Anonymous: I can't really comment on the spec...

2011-11-22T15:47:24.924-08:00

Anonymous: I can't really comment on the specifics of your mother's death. It must have been sad and traumatic for your family. I'm sorry that it went that way. Each one is unique and so many variables are involved. If your mother was "doing OK" then the use of morphine may be questioned. On the other hand if gasping, severe shortness of breath, or pain is present then morphine can be amazingly effective in symptom relief. Medical societies approve the use of morphine when the intent is to treat symptoms. No one approves its use if the intent is to kill. It might be useful to ask the doctors to review the care with your family.

When my mother died my siblings and her boyfriend ...

2011-11-22T09:03:16.964-08:00

When my mother died my siblings and her boyfriend said there "goodbyes", at which time they took her off all the machines that "kept her alive", and she started doing ok. So since she wasn't dying fast enough, they gave her morphine which lowered her blood pressure(which was the issues she was having to begin with) and it killed her. She was in a coma and was not in any pain, so why the need for morphine, if not to kill her?

Some of my most fulfilling moments come when we ha...

2011-11-20T12:57:53.819-08:00

Some of my most fulfilling moments come when we have successfully controlled someone's pain.

I do wish that people would consider hospice well before the very end. We have so many resources to offer and people on service actually live a bit longer than those not. But we still have the reputation of swooping in at the hour of death.

I briefly searched the web re "Quebec and end...

2011-11-13T13:15:29.922-08:00

I briefly searched the web re "Quebec and end of life". Several links showed up. Here's one from the Ministry of Health: http://www.chpca.net/uploads/files/english/resource_doc_library/Quebec_policy.pdf

I would imagine that Quebec would have unique cultural issues surrounding end of life care. Washington State has an End Of Life Consensus Committee (EOLCC) sponsored by the State Medical Society. It brings doctors, nurses, pharmacists, chaplains, palliative care, hospice, non-profits, and others together to work on a wide variety of issues as well to lobby for needed State wide improvements in the law and funding.

Thank you Dr. deMaine. Your blog is very instructi...

2011-11-13T07:17:41.017-08:00

Thank you Dr. deMaine. Your blog is very instructive and inspiring. I'm interested now in finding out what's being done here in Quebec around these issues. Unfortunately, there is a shortage of family doctors here that I imagine is an obstacle to end-of-life planning, among other health issues.

Thank you, Dr. Leibovich, for advocating for your ...

2011-10-23T19:52:20.141-07:00

Thank you, Dr. Leibovich, for advocating for your father until the end. I work as a hospice nurse and believe with all my heart that a peaceful death in accordance with a person's wishes is worth more than medical care at that time. You're a mensch.

I KNOW I AM 50 HAVE A BAD HEART AND ON HOSPICE CAR...

2011-10-19T14:48:40.087-07:00

I KNOW I AM 50 HAVE A BAD HEART AND ON HOSPICE CARE WE A GOLF COURSE SUP. ONE DAY GOT SICK WEN TO THE ER THYE COULD NOT FINE OUT WHAT WAS GOING ON SIGNS OF A HEART ATTACK BUT DID NOT FIND OUT WHAT WAS WRONG TO MAKE A LONG STORY SHORT HE KNEW IT WAS TIME TO GO JUST AS I DO HARD TO LIVE WENT LIFE IS NTO FULL AND NOT FAIR TO YOUR LOVE ONE TO CARRY THE LOAD SO MY IN BE A REST UNTIL HE IS COME BACK TO LIVE OF BEYOND WHAT WE CAN KNOW

Rosa, these are excellent questions. This is a pu...

2011-10-11T17:28:18.765-07:00

Rosa, these are excellent questions. This is a public health issue and lots more remains to be done. Please see my prior posts "Can We Talk About Death" and "Your Life Your Choices". Medical Schools should, I hope, be actively educating students about advance directives. Some communities and health care systems are identifying the patients most at risk by disease profile or age and directing programs toward them. Yes, physicians should be discussing end-of-life planning in an office visit beginning at age 65 or with the ill patients. I wouldn't worry too much but you might want to read more about the ethics debates in this area and see how you can become actively involved at your school. Best wishes for a productive career!

From stories like these it's easy to see the p...

2011-10-10T20:22:47.139-07:00

From stories like these it's easy to see the problems that can arise when people have not discussed their end-of-life wishes enough. But how do you spread the message and make sure more people think about these issues and make their wishes known? Should family doctors bring the issue up with all their patients? Is this a public health issue that should be dealt with at the national level? As a medical student, I haven't learned about any of this. Should I be worried?

Where I live, at least, there is a growing interes...

2011-09-29T18:47:30.894-07:00

Where I live, at least, there is a growing interest in "dying at home". Do you think this might cause a shift in the awareness of both death's reality and the need to plan for final days?

If I am dying at home, my grandkids get to see more of it, my kids are involved in more decisions, "heroic measures" aren't as easily achieved. Might that help us as a society to wrap ourselves at long last again around the fact of death and help us put the necessary provisions in place?

We can hope and indeed I do so hope. As long as the "D" word is unspeakable, those who are actually dying now are left so much out in the cold . . . or so it seems to me.

Linda Watson
http://talkaboutdeath.blogspot.com

Excellent point about consulting hospice. This ca...

2011-09-28T10:29:24.649-07:00

Excellent point about consulting hospice. This can and should be done when the family is ready to explore palliative care. Sometimes the family and medical team need more time to explore further treatment options before making the sometimes wrenching switch from "curative mode" to acceptance that they have run out of curative options and that it's time to switch to hospice for the truly remarkable care methods they offer.

In terms of who can initiate a conference, I usually found that the nurses were most aware of the family's needs for more discussion. But the doc, social worker, or family member are the other ones who can initiate things. I view the family conference in the ICU basically like a "mini Ethics Committee" which can address the concerns of all the players involved in the care of the patient.