There are the best of doctors for end-of-life care and the worst of doctors for end-of-life care.
In my last blog I told the story of two physicians. Dr. Rogers took care of my mother in the last months of her life. He is among the best of doctors for this phase of life. The other doc, I’ll call Dr. Smith, was among the not-so-good ones. I will repeat my short story
. . . I had a patient once at the nursing home whose dementia had advanced to the point where he did not know his wife, wandered the halls, and urinated in the corners. He had a long and proud career in the FBI and was now reduced to living most people’s worst nightmare. I suggested to his wife that she speak with the physician about a “No CPR” order. She reported back to me that when she requested the order, the doctor hesitated and referred to me as the “chaplain of death.”
I was shocked. Here I had done the hard work for him in addressing the emotional and spiritual issues and sent a caregiver to him requesting what, in my view, was a most appropriate order. If this patient could see himself and have a right mind, I was certain, and so was his wife, that he would welcome death. His heart stopping was the only way to be free from the dementia ravaging his mind. . . .
I am sure Dr. Smith is a fine doctor in many ways. He probably took good care of this nursing home patient. He just seemed uneasy making the shift to “comfort care only” as this patient moved toward the end of his life.
What makes the difference between the best docs and the ones who have room for improvement?
First, Dr. Rogers was more patient-centered. He tried to ascertain what my mother would have wanted and how she felt about her current condition. “How did your mother feel about her dementia?” he opened the conversation.
I wasn’t in the room with Dr. Smith and the wife of the advanced Alzheimer’s patient at the nursing home, but it appears like he was more interested in treatment orders. If he had just stopped to inquire about what the patient might have wanted, he could have spared the wife from feeling like she was asking for a death sentence.
Secondly, Dr. Rogers offered his professional opinion based his experience and a “best practices” approach at the end of life. Once he had us establish what Mom’s feelings about advanced dementia were, he told us what was needed to reach the goals of mom’s care.
The wife of the Alzheimer’s patient needed the advice of a doctor who could tell her about the limited effectiveness of CPR and the appropriateness of a “No CPR” order. She got that information from me and the doc belittled my contribution.
Lastly, Dr. Rogers saw death as the inevitable end of the course of treatment following my mom’s fractured hip. He could not stop her death although he could have recommended a treatment plan that could have prolonged her dying. She could have been sent to the hospital for hip surgery, IVs, and perhaps a feeding tube. She could have been with us for a longer amount of time. But she was going to die sooner or later as a result of this fractured hip and the advanced dementia.
Dr. Smith seemed to think death could be stopped or at least postponed. If he read the medical literature he should have known that CPR offers no hope of saving the life of this patient. Good medical care has a lot to offer patients at the end of their lives. Dr. Smith could have sought to keep the patient comfortable rather than trying to stop death with resuscitation attempts.
The Dr. Smith’s of this world are not bad people . . . maybe not even bad doctors. They just need to see death as part of life and that the physician has a role in making a passing as comfortable as can be.