• Planning Ahead: Let's Talk About Death

    How we live is important. So, too, is how we die.

    We hear a lot about how to live a good life. There are self-help books of all kinds that tell us how to live a good and happy life. As physicians, we are trained to help patients live good, healthy lives. What we hear very little about is how we die.

    We have all likely heard the statistic that one-fourth of the Medicare budget is spent on older beneficiaries in their last year of life. There are those who might dispute that fact, but the money, although important, should not be the whole argument. What we also need to talk about is the quality of that final year.

    Death is a given. Benjamin Franklin said, "In this world, nothing can be said to be certain, except death and taxes." No one gets a pass on either of these. Death is part of the natural progression of life. It comes to us all.

    How do you want to die?

    A century ago, this was not a question. Medicine was limited, and most people died suddenly from some catastrophic event. Perhaps the biggest worry was dying from "consumption," or tuberculosis. That was a slow death. Most people had to work until they died.

    I am reminded of my great-grandfather, who developed chest pain while plowing his garden with a mule and died before my father could get him to the doctor, who lived miles away. Dad told me about the moment Papa Moore went limp in his arms as he was carrying him into the doctor's home.

    Since then, medicine has advanced a long way. Today, Papa would have been on his global positioning system-guided tractor, calling 911 on his cell phone for an ambulance. He would be given CPR and clot busters in the field before arriving at the hospital, where he could get bypass surgery or, better yet, a cath and stent. Yes, we have come a long way.

    Nevertheless, what if Papa was down too long? What if they got a rhythm back but he had anoxic brain injury? Would he stay on a ventilator? Would we put a trach in when we knew we could not wean him? How about a feeding tube? These are the options modern medicine supplies -- and all too often, they raise their own questions.

    The discussion about what we want to happen in our final days should be held long before they arrive. It is a tough discussion. No one wants to talk about death if they don't think it is close at hand.

    My late wife and I had such a conversation. She told me she did not want to be kept alive on "a machine." It was unexpected, but at age 52 we had to consider such a thing. I felt the pain as I convinced her to go on a vent for "a short time." It allowed time for all the family members to say their last goodbyes. When we weaned her from the oxygen support three days later, she passed.

    She did not want to be kept on a machine. No trach, no feeding tube, no dialysis. Would you want that?

    Yes, we can do wonders, but are all these measures at the end of life heroic, or is it torture?

    My father had terminal colorectal cancer. He had survived years of diabetes, a heart attack, four-vessel bypass and congestive heart failure before cancer ultimately caused his death. Dad died at home in his sleep with my mom by his side.

    My mother-in-law had breast cancer. She was a five-year survivor. Seven years after first diagnosis -- and after chemo and radiation therapy left her in a weakened state -- she passed away at home with hospice care.

    My mother told me, "I don't want to go to a home," so we were able to keep her in her own home until she passed with Alzheimer's dementia.

    The only times my mother was ever a patient in a hospital was to have her children. Dad had colon cancer and bypass surgeries and repeated bouts of CHF. My mother-in-law had a mastectomy, reconstructive surgery and a pulmonary embolism, and she delivered her children in the hospital. However, all three of them chose to be with family at home when they passed. They did not want the fluorescent light-flooded, cold hospital bed to be their final experience on earth. They wanted to be around those they loved and to feel the familiar surroundings they had grown to love over the years.

    Dying in America has changed, but our comfort level in discussing it has not -- we still find it hard to do so. But we need to discuss death with our patients. Ask yourself, what do you want in those final months, weeks, days or hours? Then give your patients the same respect and consideration you would want yourself. Find out what they want. Consider hospice for the terminally ill. Consider palliative care for those with chronic disease. Advise your patients to complete a living will, and make sure they understand what advance directives mean.  

    The AAFP has policies to guide family physicians through advance planning and end-of-life care, and American Family Physician has compiled a collection of journal articles and patient education materials related to end-of-life care. Whether you're just beginning the conversation with a patient or finalizing an advance care plan, these resources can be invaluable.

    Most importantly, don't neglect to answer this question for yourself: How do you want to die? Planning ahead will make things easier not only for you, but for those you love.

    Leonard Reeves, M.D., is a member of the AAFP Board of Directors.


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