TIME health

Why Dying Is Easier for Doctors

Elderly Person Hand
BSIP—UIG via Getty Images

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This piece originally appeared at Zocalo Public Square.

For all the effort they spend fending off the deaths of others, they tend to be fairly serene when faced with their own death

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This piece originally appeared at Zocalo Public Square.

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TIME How-To

Manage What Happens to Your Online Accounts After You Die

computer keys
Jamie Grill / Getty Images

Consider the size of your online presence—your Facebook account, which details your daily life and personal history; your email account, which contains a wealth of your personal and business communications; photos, music and documents you have stored in the cloud; online banking accounts and records; frequent flier miles and more.

What happens to all this stuff when you die?

Will heirs be able to access your accounts to manage your affairs or do you want to prevent them from snooping around in virtual territory you want kept private? Will your accounts simply evaporate over time or will your Facebook page still be up long after you’re gone?

While some people don’t care, others find the idea of their digital assets outliving them disconcerting. Creating a digital will helps you determine which accounts survive and which you take to your grave.

How to Create a Digital Will

The U.S. government wrote a blog post about this very topic and suggested that people create social media wills that spell out how their online identities are to be handled after death. To do it, you should:

  1. Appoint someone as an online executor. Because you’ll be leaving this person with the keys to your digital kingdom, this person should be someone who is willing to put in the time and effort to close or memorialize your accounts, capable of protecting your sensitive information from identity thieves or snoopers, tech-savvy enough to be able to make changes to your accounts and trustworthy to carry out your wishes.
  2. State in a formal document how you want your profiles and accounts to be handled. For example, do you want your email account deleted without anyone reading your messages? Do you want your Facebook account deactivated or would you rather have your Timeline memorialized (meaning only friends can see your page and leave posts in remembrance)?
  3. Understand the privacy policies of each website with which you’re associated. You should know that unless you leave your online executor your passwords, there might not be much he or she can do. Google, for example, won’t let anyone into your email account without that person putting forth an application and undergoing a formal and lengthy process and, even then, he or she might not get in. Same goes with Facebook.
  4. Provide your online executor a list of all the websites and login credentials for which you want he or she to take action. If someone makes changes to your account by pretending to be you it may violate a website’s terms of service, but legally your designation of an online executor is akin to granting a limited power of attorney.
  5. State in your will that the online executor should have a copy of your death certificate. This may help him or her take action on your behalf with various websites and accounts.

Working With Your Lawyer On a Digital Will

Julie Min Chayet, managing director and trust counsel for Fiduciary Trust Company International in New York City, says the idea of a digital will hasn’t become mainstream. However, clients do ask attorneys to include all sorts of requests in their Last Will and Testament, so requesting that someone clean up a digital footprint online is perfectly acceptable and recommended.

Chayet says the executor named in your Last Will and Testament has to settle all matters relating to one’s life—financial or otherwise—and you can specify that this person also should handle your online accounts.

“From a legal standpoint, the responsibilities of a court appointed executor or administrator include shutting down digital assets and accounts. It’s just important to be clear about what needs to be done with information and for the not-too-tech-savvy executor it is important to be explicit about next steps,” she says.

For example, you could leave a written statement to be posted on your Facebook account.

“It’s comparable to someone planning his or her own funeral down to every last detail of choosing the burial site, the music to be played, clothing to be worn, flowers displayed, poems or readings to be read and food to be served,” Chayet says. “Settling an estate is incredibly stressful and emotional. Being prepared will only help your loved ones in every aspect of their mourning.”

Websites That Can Help

While you can certainly keep your digital asset information on paper to be handed over to your online executor once you die, the reality is passwords frequently change and keeping an up-to-date paper list can be a pain. Instead, many password management websites offer features that will turn your digital assets over to others at the appropriate time.

Password Box’s Legacy Locker feature lets you identify your online assets and login credentials as well as “verifiers”—people you trust to handle your online accounts after your death. Once you have passed away, your verifiers must contact Password Box, confirm their identities and the website transfers your account information to them as well as any letters you may have left at the site for family, friends or colleagues.

Price: The first 25 saved passwords are free. Additional password slots can be purchased for $12/year.

SecureSafe is similar to Legacy Locker, but adds various amounts of file storage along with password management and transfer to beneficiaries.

Price: Several pricing and storage tiers are available, starting with a free account that gives you 50 password slots and 10 megabyes of storage.

This article was written by Christina DesMarais and originally appeared on Techlicious.

More from Techlicious:

TIME Crime

Grand Jury to Be Convened in Eric Garner Chokehold Death

Eric Garner died after being placed in a chokehold by police last month

A special grand jury will be convened to determine whether or not to charge police officers in the July chokehold death of a Staten Island man, District Attorney Daniel Donovan announced Tuesday.

A cellphone video of the incident shows deceased Eric Garner, 43, saying “I can’t breathe” after a New York Police Department officer later identified as Daniel Pantaleo placed him in a chokehold. Such a move is banned by the NYPD although permitted under state law. Officers were attempting to arrest Garner on suspicions of selling single cigarettes outside of a store. The medical examiner’s office ruled Garner’s death a homicide.

“I have determined that it is appropriate to present evidence regarding the circumstances of [Eric Garner's] death to a Richmond County Grand Jury,” said a statement released by Donovan’s office to SILive. “Yesterday, the Court granted my application for the impaneling of an additional Grand Jury and I intend to utilize that Grand Jury sometime next month to begin presenting evidence on this matter.”

The special grand jury would have to unanimously vote to indict either Pantaleo or another officer. No witnesses have been named.

[SILive]

 

TIME Television

Watch David Letterman Pay Tribute to Robin Williams on Late Show

"I had no idea the man was in pain"

David Letterman returned to the Late Show on Monday and paid tribute to his friend, the late Robin Williams, who had died while the show was on a summer break.

Letterman had known Williams for 38 years. They met at the the Comedy Store in West Hollywood, where Letterman says he watched Williams’ first set at the club.

During his tribute, Letterman lamented Williams’ passing and his depression. “I had no idea that the man was in pain, that the man was suffering,” he said.

TIME Television

Watch Late Night Hosts Pay Tribute to Robin Williams

Jimmy Fallon, Seth Meyers and Conan O'Brien remember the late comedian during their shows

Late night hosts including Jimmy Fallon and Seth Meyers addressed the death of Robin Williams Tuesday night. Tonight Show host Fallon, near tears, said, “He was one of a kind. He was one in a million.” Meyers took a moment to express his condolences to Williams’ family on his show, Late Night with Seth Meyers.

Late night host Conan O’Brien earlier broke the news to his audience during the taping of his show Monday night. He told his audience Tuesday night, “What I think a lot of people don’t know…is how crazily generous– he was so generous.”

TIME celebrities

Robin Williams Hanged Himself, Police Say

Robin Williams before his performance at the Ted Constant Convocation Center in Norfolk
Robin Williams before his performance at the Ted Constant Convocation Center in Norfolk, Va., on Oct. 28, 2009 Jay Paul—The New York Times/Redux

Confirming reports he committed suicide

Robin Williams died because of asphyxia from hanging himself in his California home, police said Tuesday, confirming a day after the actor’s death that he had committed suicide.

The Marin County Sheriff’s Office also said Williams, who was 63, suffered “acute superficial” cuts to his wrist, and that a pocket blade was found near his body. A forensic examination showed no signs of a struggle, and toxicology results for Williams, who had long struggled with substance abuse and depression, won’t be available for about two to six weeks, police said.

Williams was last seen by his wife at 10:30 p.m. local time on Sunday when she went to bed. Williams’ personal assistant became concerned the next day when the actor failed to respond to knocks on his bedroom door. Upon entering, the assistant found Williams “clothed in a seated position, unresponsive, with a belt around his neck,” Lieutenant Keith Boyd told reporters during a news conference. He was pronounced dead shortly after noon on Monday.

Fans of the late comedian and actor gathered near the news conference in San Rafael, Calif., on Tuesday.

“It surprises me that someone who was so loved felt so alone,” said Leigh Carliglio of Contra Costa County. “He was loved, he was wonderful. This is devastating.”

She particularly remembers Mork & Mindy and then quickly adds Mrs. Doubtfire and Aladdin. “All of them.”

She was surprised to find out how he died. “We need more care for mental-health patients. We don’t understand how deep depression runs.”

Other fans filmed the news conference with their cell phones, lamenting how “a whole generation” grew up with Williams’ character in Mork & Mindy.

Outside Williams’ home in nearby Tiburon sat flower bouquets and notes address to “Robin.” A few fans lingered. “Anything he was in, I would go see it,” one said. “It’s just devastating. I have depression in my family.”

— Katy Steinmetz reported from San Rafael and Tiburon, Calif.


TIME celebrity

WATCH: Hollywood Reacts to Death of Robin Williams

Comedians, actors and entertainers pay tribute to the late star

Like the rest of the nation, actors, comedians and entertainers were shocked by the sudden death of superstar talent Robin Williams. Celebrity reactions to his apparent suicide have flooded media both social and traditional, with many paying tribute to their own personal relationships with the late star.

Steve Martin referred to him as a great talent and a genuine soul. Kathy Griffin tweeted of how every moment shared with Williams was a pivotal one, and that it was a comic’s dream to be in his presence. Judd Apatow wrote about the lengths he went to simply be near the legendary comic, saying that he took an internship at Comic Relief at the age of 18 in order to work with Williams.

Billy Crystal wrote poignantly, “No words.”

Other comedians such as Jimmy Kimmel and Chelsea Handler marked the tragedy by attempting to raise awareness of depression, telling those in need of support to not be afraid to reach out for help, and to remain strong.

TIME movies

Where to Watch Robin Williams’ Best Movies

Today
Actor Robin Williams talks about his film, "License to Wed" on NBC News' TODAY on June 28, 2007 NBC NewsWire--NBC NewsWire via Getty Images

Looking to revisit some of your favorite Robin Williams film moments? Here's a list of places to watch online

With the news that actor and comedian Robin Williams has died at age 63—he was found at his home in California after an apparent suicide on Monday—fans around the world have been left reeling.

From Twitter to late night, tributes have poured in for a man who, for many, defined comedy. From the tone and emotion behind many of the remembrances, it’s become apparent that there are many people who not only admired the actor—they felt genuinely moved by him. Whether it was Mork from Mork and Mindy or Dr. Sean Maguire in Good Will Hunting or the Genie from Aladdin, everyone seems to have their own favorite Robin Williams moment or character that they hold dear. It’s not surprising: Williams was an absolute master of creating a character that resonated with people one way or another.

For those looking to revisit your favorite Robin Williams moment—or even camp out and watch a whole marathon of his movies—we’ve compiled a list of places where you can stream or rent online some of his best and most memorable films.

  • Popeye (1980) — Netflix
  • Good Morning, Vietnam (1987) — Amazon
  • Dead Poets Society (1989) — Amazon
  • Awakenings (1990) — Amazon
  • The Fisher King (1991) — Netflix
  • Hook (1991) — Netflix
  • Mrs. Doubtfire (1993) — Amazon
  • Jumanji (1995) — Netflix
  • The Birdcage (1996) — Netflix
  • Good Will Hunting (1997) — Hulu
  • Patch Adams (1998) — Amazon
  • What Dreams May Come (1998) — Amazon
  • Insomnia (2002) — Amazon
  • One Hour Photo (2002) — Amazon
  • Man of the Year (2006) — Amazon
  • Night at the Museum (2006) — Amazon
TIME celebrities

Watch Conan O’Brien Announce Robin Williams’ Death to a Stunned Audience

“God bless Robin Williams”

Late-night comedian Conan O’Brien had almost wrapped up his Monday night show when news broke that his friend and fellow comic Robin Williams had died.

A visibly stunned O’Brien then told the hushed studio audience, apologizing to them for having to do so. Co-host Andy Richter and guest Will Arnett appeared shocked.

“This is absolutely shocking and horrifying and so upsetting on every level,” said O’Brien. “We’re at the end of the show and it felt like it needed to be acknowledged.”

Arnett went on to poignantly reminisce on the kindness Williams had always shown to friends and colleagues.

“He was even better as a person,” said Arnett. “He was one of the loveliest and sweetest and kindest guys I’ve ever worked with.”

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