When I am feeling self-assured, I can contend that aging is not a disease we can treat, that death is unavoidable, and that with even the most extreme efforts, crises at the end of life are often inevitable.
Do you mean he dies before his next trip to ER or that he has 4 more trips to ER before he dies? For my money & life, 4 more ER trips before dying would be thaw bad ending
Sign of a good life and likely many good decisions. Staying out of hospitals as much as feasible is also a good life skill to have. 97 and still able to make his own decisions, live as he wants, go for walks, talk to his niece everyday. Pray that every good person should be so fortunate.
You accede to the patients wishes to be treated less aggressively. So did I before retiring. What other choice do you have, other than discharge them or commit them as insane? But what about the patient that wants unjustified testing or procedures? You don't accede to them readily, do you?
I remember having a realization at some point, early on in being an attending, that I simply couldn't make my patients do anything. They had to want it. And not only was I incapable of forcing them, I wasn't sure I wanted to force them, anyway.
I still stand by radical bodily autonomy as a core principle of medicine. But it does open up big questions - what is the purpose of the doctor? What role can and should I play? And as patients get more access to information online - often the exact same information I have access to - I grapple with what role we doctors play, at all.
I think this patient's story already has a happy ending. First, being able to understand and articulate his preferences speaks to the quality of care he has received up to this point, as well as of being in an optimal psychological state. He is given the gift of autonomy, one that we all deserve as human beings. He alone knows what constitutes a "good ending" for himself, and he chose it. Bravo to you for not browbeating him. We should all be so fortunate to outlive the actuarial tables and have such choices in our waning days.
I doubt it! Dr. Cifu's patient has already made it to age 97 with independence, far more than almost all Americans, and putting him amongst the top 0.001 percentile on the planet. Only some trees, and many lies and racist beliefs have a longer average lifespan.
A bad ending is happening daily in Gaza, South Sudan, Ukraine, all over Africa and even to young people dying prematurely in North America. In Toronto, Canada, a sweet 8 y/o boy was killed by a stray bullet last week.
Meanwhile in rich countries, many people are lingering for years in states of complete dependence, no longer recognizable as the complete and often wonderful human beings they once were.
I take Dr. Cifu's posting as parable, with a taste of Jonathan Swift. And I'm looking forward to meeting him at the Preventing Overdiagnosis conference in Oxford a couple of weeks from now.
I found recently that reading Stefan Zweig: The World of Yesterday (published 1942) helped put many modern conundrums in context - including how easily and rapidly advanced civilizations lose freedom and collapse into barbarism. Many readers would recognize not only echos, but premonitions about where we are all being dragged in 2025.
Tom Perry MD (general internist, clinical pharmacologist)
It may pose an even harder challenge for those of us without children or young family to check in on us. Technology will help, we'll see when and if I make it to be old enough to need help.
The other angle I see is that of course seniors want to stay in the home they have always been in but they are too often a home that could house a whole family but is just housing the one person for years or decades. There should really be more options for downsizing without moving so far from the place you've lived.
As a car guy, you should give more love to The French Connection. In the GOAT discussion for best car chase scene ever. 😉
I’m always impressed by your caring and humanity. However, I do fall back on patient autonomy. If a patient is competent, and understands his choices…well, choices have consequences, and patients are entitled to them.
But I do acknowledge another level of discussion about societal/health care costs, which may have disparate implications in different healthcare systems.
I really appreciate your quandary, your honesty, and your caring.
I'll offer the following counter-ideas, if you will.
First, we all die, and it's a difficult process for not only the patient but also the caregivers and family/friends. That's a given. Yet I have trouble reconciling my own inevitable death with the notion of passing on inevitable debt, given how "big medicine" is now organized as a cash machine for its "owners." (Yes, that's a very cynical comment.) That's why rural (i.e., not profitable) hospitals are closing.
But I keep tripping on the notion that, barring being a danger to others, why shouldn't people be allowed to make decisions that appear irrational to other people? Just whose life is it? Why, when a person ages, do we almost automatically decide they are no longer competent?
Why do we get involved in telling someone they are making the wrong decision when they've clearly thought about it and decided against the logical arguments we all know or can access?
The fact is, we all start dying from the moment we are born. Instead of pushing another into treatment(s) they don't want, why not concentrate on making each moment count? We don't get those moments back, no matter how many more continue to appear ahead of us.
“The secret of the care of the patient is in caring for the patient," Dr. Francis Peabody
And I’ll add Dr. Cifu.
One of the hardest things in my own work was when a patient decided to continue drinking/using, knowing the outcome. I always made sure that they KNEW we wanted what was best for them and to come back when ready. Sometimes that’s all we can do.
My monthly "chronologically gifted" nurses group recently had a conversation centered on the theme of how to avoid dying like Gene Hackman. The takeaway: many of us don't have plans in place, and denial is prevalent. As Tanya Tucker sang: we all think we've got the time, until we don't.
Do you ever run into cases where the patient wants more intervention than you think advisable? Do you similarly defer to their wishes in that scenario as well? I know a few elderly people who would probably fall into that category.
Thank you for the humanity you bring to your care for your patients. As a dentist and having practiced for more than 50 years, certainly I don’t deal with the life and death issues illustrated by the gentleman. But much of what I do does bear directly on matters of quality of life. In some cases, conditions I deal with overlap with the approach of end-of-life of some patients. Very often “less is more” is the most appropriate and humane approach. While I can disagree with a choice a person might make, I hope I never fail to respect that person’s dignity and ultimate autonomy to choose. Thank you Dr Cifu for being an example well worth following.
Thank you for a wonderful reflection. Actually, the word reflection doesn't do it justice. This is the essence of good medical care and should be read by everyone that is involved in the medical care system.
Great piece!
Bad ending?
Do you mean he dies before his next trip to ER or that he has 4 more trips to ER before he dies? For my money & life, 4 more ER trips before dying would be thaw bad ending
Sign of a good life and likely many good decisions. Staying out of hospitals as much as feasible is also a good life skill to have. 97 and still able to make his own decisions, live as he wants, go for walks, talk to his niece everyday. Pray that every good person should be so fortunate.
Learned Helplessness
You accede to the patients wishes to be treated less aggressively. So did I before retiring. What other choice do you have, other than discharge them or commit them as insane? But what about the patient that wants unjustified testing or procedures? You don't accede to them readily, do you?
Well, you know people are free in the US to choose what they will.
I remember having a realization at some point, early on in being an attending, that I simply couldn't make my patients do anything. They had to want it. And not only was I incapable of forcing them, I wasn't sure I wanted to force them, anyway.
I still stand by radical bodily autonomy as a core principle of medicine. But it does open up big questions - what is the purpose of the doctor? What role can and should I play? And as patients get more access to information online - often the exact same information I have access to - I grapple with what role we doctors play, at all.
I think this patient's story already has a happy ending. First, being able to understand and articulate his preferences speaks to the quality of care he has received up to this point, as well as of being in an optimal psychological state. He is given the gift of autonomy, one that we all deserve as human beings. He alone knows what constitutes a "good ending" for himself, and he chose it. Bravo to you for not browbeating him. We should all be so fortunate to outlive the actuarial tables and have such choices in our waning days.
"I expect this story will have a bad ending."
I doubt it! Dr. Cifu's patient has already made it to age 97 with independence, far more than almost all Americans, and putting him amongst the top 0.001 percentile on the planet. Only some trees, and many lies and racist beliefs have a longer average lifespan.
A bad ending is happening daily in Gaza, South Sudan, Ukraine, all over Africa and even to young people dying prematurely in North America. In Toronto, Canada, a sweet 8 y/o boy was killed by a stray bullet last week.
Meanwhile in rich countries, many people are lingering for years in states of complete dependence, no longer recognizable as the complete and often wonderful human beings they once were.
I take Dr. Cifu's posting as parable, with a taste of Jonathan Swift. And I'm looking forward to meeting him at the Preventing Overdiagnosis conference in Oxford a couple of weeks from now.
I found recently that reading Stefan Zweig: The World of Yesterday (published 1942) helped put many modern conundrums in context - including how easily and rapidly advanced civilizations lose freedom and collapse into barbarism. Many readers would recognize not only echos, but premonitions about where we are all being dragged in 2025.
Tom Perry MD (general internist, clinical pharmacologist)
It may pose an even harder challenge for those of us without children or young family to check in on us. Technology will help, we'll see when and if I make it to be old enough to need help.
The other angle I see is that of course seniors want to stay in the home they have always been in but they are too often a home that could house a whole family but is just housing the one person for years or decades. There should really be more options for downsizing without moving so far from the place you've lived.
As a car guy, you should give more love to The French Connection. In the GOAT discussion for best car chase scene ever. 😉
I’m always impressed by your caring and humanity. However, I do fall back on patient autonomy. If a patient is competent, and understands his choices…well, choices have consequences, and patients are entitled to them.
But I do acknowledge another level of discussion about societal/health care costs, which may have disparate implications in different healthcare systems.
I am with you, the car chase in FC is next level.
I really appreciate your quandary, your honesty, and your caring.
I'll offer the following counter-ideas, if you will.
First, we all die, and it's a difficult process for not only the patient but also the caregivers and family/friends. That's a given. Yet I have trouble reconciling my own inevitable death with the notion of passing on inevitable debt, given how "big medicine" is now organized as a cash machine for its "owners." (Yes, that's a very cynical comment.) That's why rural (i.e., not profitable) hospitals are closing.
But I keep tripping on the notion that, barring being a danger to others, why shouldn't people be allowed to make decisions that appear irrational to other people? Just whose life is it? Why, when a person ages, do we almost automatically decide they are no longer competent?
Why do we get involved in telling someone they are making the wrong decision when they've clearly thought about it and decided against the logical arguments we all know or can access?
The fact is, we all start dying from the moment we are born. Instead of pushing another into treatment(s) they don't want, why not concentrate on making each moment count? We don't get those moments back, no matter how many more continue to appear ahead of us.
“The secret of the care of the patient is in caring for the patient," Dr. Francis Peabody
And I’ll add Dr. Cifu.
One of the hardest things in my own work was when a patient decided to continue drinking/using, knowing the outcome. I always made sure that they KNEW we wanted what was best for them and to come back when ready. Sometimes that’s all we can do.
"Come back when ready" is often REALLY good advice.
My monthly "chronologically gifted" nurses group recently had a conversation centered on the theme of how to avoid dying like Gene Hackman. The takeaway: many of us don't have plans in place, and denial is prevalent. As Tanya Tucker sang: we all think we've got the time, until we don't.
Do you ever run into cases where the patient wants more intervention than you think advisable? Do you similarly defer to their wishes in that scenario as well? I know a few elderly people who would probably fall into that category.
Maybe this one?
https://www.sensible-med.com/p/friday-reflection-9-it-is-hard-to?utm_medium=reader2&utm_source=profile
Thank you for the humanity you bring to your care for your patients. As a dentist and having practiced for more than 50 years, certainly I don’t deal with the life and death issues illustrated by the gentleman. But much of what I do does bear directly on matters of quality of life. In some cases, conditions I deal with overlap with the approach of end-of-life of some patients. Very often “less is more” is the most appropriate and humane approach. While I can disagree with a choice a person might make, I hope I never fail to respect that person’s dignity and ultimate autonomy to choose. Thank you Dr Cifu for being an example well worth following.
Thank you for a wonderful reflection. Actually, the word reflection doesn't do it justice. This is the essence of good medical care and should be read by everyone that is involved in the medical care system.