TIME medicine

The Right—and Right Time—to Die: How Doctors Should Help

Jauhar is a cardiologist and the author of Doctored: The Disillusionment of an American Physician.

I've tried to fight a patient's inevitable death, but I know that's not always the best care—and America needs to talk about what is

As doctors, we are expected to prolong human life, and we do—but often regardless of the costs. Brittany Maynard, the 28-year-old Oregon woman with an inoperable brain tumor, puts a human face on this tragedy. Maynard has decided that she does not want to suffer through a painful, protracted death and is planning to end her life with doctor-prescribed pills, obtained through Oregon’s Death With Dignity Act; she may have died by the time you read this. In Oregon, more than 1,100 people have obtained life-ending prescriptions since the law’s passage in 1997, and about 750 have used them safely and appropriately. By numerous accounts, the law has been a success. And yet many doctors, not to mention laymen, continue to regard its goals with suspicion. I have been one of those doctors.

I once cared for an 88-year-old patient with a severely leaky heart valve. When she was hospitalized with worsening kidney and heart failure, a critical-care specialist decided to forgo aggressive treatment. But unwilling to give up, and against my better judgment, I transferred her to the cardiac intensive-care unit. Her stay there was a disaster. She was unable to be weaned from a respirator. Her liver failed. Even as it became clear to me that she was going to die and that my interventions had been for no good purpose, I became very reluctant to change course. We checked blood tests several times per day. I inserted a pressure catheter in her pulmonary artery to monitor her hemodynamics. I started her on dialysis. The breathing tube remained in her throat till the end. Eventually she succumbed to multi-system organ failure and sepsis, nearly a week after I’d moved her to the ICU.

At their core, my actions were a kind of deception—convincing myself, despite the evidence, that I could save my patient and stay the inexorable course of her disease. Perhaps I was embarrassed by my impotence or afraid to see a beloved patient pass. I don’t know. But it was the kind of deception that many in my profession practice.

Of course, it isn’t only doctors who medicalize the terminal phase of life. Patients and their families do too. I once took care of a middle-aged man in the ICU who’d had a cardiac arrest and ended up with significant brain damage because he had been out so long. His wife would not accept the terminal nature of his condition. “He is going to pull out of this,” she told me adamantly. When I asked if her husband had ever expressed any preferences about being on life support, she told me what I expected: they had never discussed it.

That conversation is often the crux of the problem. Most people never have it, thus families and doctors are left to substitute their own judgments and prejudices for those of the patient. What does a dying patient want? What is the minimum quality of life that is acceptable to him or her? As Maynard has so poignantly shown us, these are questions we need to ask before it is too late. And it’s not just families who need to have the tough talk. As a nation, we need to rethink our approach to dying and death. Our reluctance to confront mortality is the cause of too much suffering.

Most Americans die in a hospital or a nursing home. Almost one-third of the $554 billion we spent on Medicare in 2011 was used to treat people in the last six months of their lives. Nearly every colleague I’ve talked to recognizes that this wastes precious resources and prolongs suffering. But they—I—have not been taught a different way.

Hospice is one alternative. The modern hospice movement started in 1967, when Dame Cicely Saunders, a nurse, opened St. Christopher’s Hospice in London. Saunders formulated three principles for easing the process of dying: relief of physical pain, preservation of dignity, and respect for the psychological and spiritual aspects of death. Though it’s been slow, progress has been made. The number of American hospitals offering palliative care has nearly doubled since 2000, growing to nearly 1,500 programs—the majority of hospitals. Yet even as reflective an observer as Atul Gawande admits in his new book, speaking no doubt for the majority of physicians, “The picture I had of hospice was a morphine drip.”

Doctors witness death and dying nearly every day. Disease may win in the end, but we must strive to never lose sight of the patient at the center of it all, and we must empower our patients to make their own decisions in the terminal phase of their lives. Maynard’s terrible tale reminds me of what an elderly woman with terminal heart disease once told me: “My husband said the hardest thing to do is to die; I always thought it would be easy.”

 

Jauhar is a cardiologist and the author of two books, Intern: A Doctor’s Initiation and the recently published Doctored: The Disillusionment of an American Physician

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Healthcare

One Patient, Too Many Doctors: The Terrible Expense of Overspecialization

Doctored, by Sandeep Jauhar
Doctored, by Sandeep Jauhar Courtesy Farrar, Straus and Giroux

As physicians become more specialized, our health care system becomes increasingly costly, sloppy and disorganized

Not long ago, a primary-care physician called me about a patient with a right-lung “consolidation” — probably pneumonia, though a tumor could not be excluded — that a lung specialist had decided to biopsy. My colleague wanted me to provide “cardiac clearance” for the procedure.

“Sure, I’ll see him,” I said, sitting in my office. “How old is he?”

“Ninety-two.”

I stopped what I was doing. “Ninety-two? And they want to do a biopsy?”

My colleague, who is from Nigeria, started laughing. “What can I tell you? In my country we would leave him alone, but this is America, my friend.”

Though accurate data is lacking, the overuse of health care services in this country probably costs hundreds of billions of dollars each year out of the $3 trillion that Americans spend on health. This overuse is driven by many forces: “defensive” medicine by doctors trying to avoid lawsuits, a reluctance on the part of doctors and patients to accept diagnostic uncertainty (thus leading to more tests), lack of consensus about which treatments are effective, and the pervading belief that newer, more expensive drugs and technology are better. However, perhaps the most important factor is the overspecialization of the American physician workforce and the high frequency with which these specialists are called by primary-care physicians for help.

The past half-century has witnessed great changes in American medicine. One of the biggest shifts is the rise of specialists. In 1940, three-quarters of America’s physicians were general practitioners. By 1960 specialists outnumbered generalists, and by 1970 only a quarter of doctors counted themselves general practitioners. This increase paralleled an equally dramatic rise in medical expenses, from $3 billion in 1940 to $75 billion in 1970.

Specialist-driven care has now become a fact of medical practice. In the past decade, the probability that a visit to a physician resulted in a referral to a specialist has nearly doubled, from 5% to more than 9%. Referral rates to specialists are estimated to be at least twice as high in the U.S. as in Britain.

The consequences for patients are troubling. Besides high costs, having too many consultants leads to sloppiness and disorganization. As Drs. Donald Berwick and Allan Detsky recently wrote in the Journal of the American Medical Association, inpatient care at hospitals has become a relay race for physicians and consultants, and patients are the batons.

I remember a 50-year-old patient of my Nigerian colleague who was admitted to the hospital with shortness of breath. During his monthlong stay, which probably cost upward of $100,000, he was seen by a hematologist; an endocrinologist; a kidney specialist; a podiatrist; two cardiologists; a cardiac electrophysiologist; an infectious-disease specialist; a pulmonologist; an ear, nose and throat specialist; a urologist; a gastroenterologist; a neurologist; a nutritionist; a general surgeon; a thoracic surgeon; and a pain specialist. The man underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to investigate only mild anemia). Every day he was in the hospital, his insurance company probably got billed nearly $1,000 for doctor visits alone. When he was discharged (with only minimal improvement in his shortness of breath), follow-up visits were scheduled for him with seven specialists.

This case — in which expert consultations sprouted with little rhyme, reason or coordination — reinforced a lesson I learned many times in my first year as an attending physician: in our health care system, if you have a slew of specialists and a willing patient, almost any sort of terrible excess can occur.

What to do about this overspecialization? One option is accountable-care organizations, an idea put forward by the Affordable Care Act, in which teams of doctors would be responsible (and paid accordingly) for their patients’ clinical outcomes. This would force specialists to coordinate care. Unfortunately, most doctors, notoriously independent and already smothered in paperwork, have generally performed poorly in this regard.

Reforms will also have to focus on patient education. Medical specialty societies recently released lists of tests and procedures that are not beneficial to patients. By using these lists, cardiologists have been able to decrease their use of imaging tests by 20%. Better-informed patients might be the most potent restraint on overspecialized care. A large percentage of health care costs is a consequence of induced demand — that is, physicians persuading patients to consume services they would not have chosen had they been better educated. If patients were more involved in medical decisionmaking, there would be more constraints on doctors’ behavior, decreasing the possibility of unnecessary testing. This could serve as a potent check on what the doctor ordered.

Today roughly 1 of 6 dollars spent in America goes toward health care. If we do not succeed in controlling these costs, they will gradually crowd out other necessary societal expenditures. Improving health literacy will be critical to these efforts. Without a better understanding of what doctors are actually doing, one may end up like the patient who had 17 consultants and 12 procedures and who reinforced a further lesson I have learned many times since entering practice: when too many specialists are involved in a case, the result too often is waste, disorganization and overload.

Jauhar is a cardiologist and the author of Intern: A Doctor’s Initiation and the new memoir, out today, Doctored: The Disillusionment of an American Physician

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