Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Absolutely terrible thread title, BTW.

Agreed, it is a disgusting title.

I am an attorney who changed careers and have been working in mostly hospice care for the last near decade. The majority of my patients have been elderly, but some were DNR based on chronic degenerative conditions at younger ages.

I’ve noticed that the majority of doctors are just as uncomfortable as the average person with having conversations about death. They may be more matter of fact about it in their own thinking, but they don’t really want to talk about it with patients. There is a lot of avoidance of spelling things out plainly to people who are avoiding accepting it themselves. Even some doctors and nurses who work in HOSPICE, whose jobs are all about helping dying patients die, sometimes push too far to keep people on the alive side of things even if it means prolonging discomfort.

I can’t agree with your OP at all, not the ugly thread title. The truth is that the situation in American medicine is overwhelmingly the flip side of the coin - we spend astronomically to keep people alive in the final years or months, and often causing much anguish in the process for patients and families alike. All because we can’t talk about death in this country and most folks are terrified of it.

As to your parents OP - this is a well tread area of medical ethics and not some ageism bias of the doctors. When patients are in their 80s and beyond, they are statistically much less likely to fully recover from many procedures and treatments - exponentially less likely than a patient in their 50s, 60s, or even 70s. Same with their statistical likelihood of experiencing complications which hasten greater disability and/or death.

This factors into the physician’s determination of what is in the best interests of the patient, and no doctor is required to perform a surgery or treatment on a patient if they feel it is going against their best interests. Some doctors are skilled at explaining this and others just hem and haw and avoid flat out saying how things are. It has nothing to do with a lack of caring about your loved one. I would argue that there is more caring on offer from someone who nudges you in the direction of recognizing your impending mortality than in steering you toward further denial.

The patient alone determines what is best for them. Physicians may be learned intermediaries but they have no right to decide whether a patient gets treatment or not. They have a duty to explain all options and the likely results of each. If they can’t do that, they should switch to pathology.

Not everyone who resists being “nudged” toward the beyond is in denial. Some just have more hope than the people doing the nudging.

No, patients don’t dictate their care. You can’t just order a doctor to do this or that, if it’s not medically indicated. No wonder so many people are leaving the medical field. You think you can boss them around like they’re your nanny.

While medical arrogance may know no boundaries, it is the physician’s duty to explain options and associated prognoses. Failure to do so is prima facie negligence. What is “medically indicated” is a matter of opinion, and patients have a right to have that opinion and the grounds for it made clear. Hiring a physician to provide services does not create a custodial relationship where the physician holds the power of life and death to be exercised at his or her caprice. Oh, and I don’t “think” I can boss the Great Exalted around, I know I can, and I do.

Ooh, big talk. Sorry, no doctor is going to perform any procedure that they think is unjustified. Well, maybe your shitty one, but then you have a shitty doc. So there’s that. And I’m laughing at you thinking you know better than a doctor what’s medically indicated. Where did you get your MD?

They may not know more medically but they sure as heck know a lot about how doctors view, value, and correspondingly treat their Black patients.

There was no indication that race was an issue in the PP's ego-driven piffle above. They're just pounding their chest on the internet.

I feel the opposite way. My in-laws are in their late 80s and I'm shocked at all the medical care they've received. My MIL was hospitalized for a long time last fall and she was very close to peacefully passing away without to much drama. But the hospital would not let her go and kept pushing food, medicine, drugs, therapy etc. It never got to the CPR point so I don't know what her DNR preference truly is. She then went on to spend months in a rehab facility. She's now at home but my FIL seriously struggles to provide care for her physical issues as well as dementia which got substantially worse after her hospitalization. Its been a huge mess and its not like her quality of life will improve at this point. Its hard for the family in the moment to say stop caring for my loved one. Although DH and his siblings have now agreed they think she would have preferred a more dignified death and will advocate differently the next time.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I think in an ideal world doctors could give their all to everyone. The reality is they are understaffed, very overworked and many are burned out. Since they are not superhuman, would you rather a doctor give more attention to a mother or father with children at home, one of whom may have special needs or medical issues or emotional struggles or put all their energy into giving your elderly parent a few more months?

DP, but obviously my parents are more important to me than some random stranger’s kids. Let’s not start moving eugenics-ward, shall we?

Sure, but you’re kind of shitty if you’d rather your elderly parents have 3 more years of life than a 20 year old have another 50-60.

You are a ghoul.

No, I'm a pragmatist. I get that you love your parents; I love mine. But if care has to be rationed, and my 81 year old father is up against it with someone less than half his age, I couldn't in good conscience make an argument for my father to get the care. And frankly, my father would agree. After all, he's the one who raised me and inculcated my values.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Absolutely terrible thread title, BTW.

Agreed, it is a disgusting title.

I am an attorney who changed careers and have been working in mostly hospice care for the last near decade. The majority of my patients have been elderly, but some were DNR based on chronic degenerative conditions at younger ages.

I’ve noticed that the majority of doctors are just as uncomfortable as the average person with having conversations about death. They may be more matter of fact about it in their own thinking, but they don’t really want to talk about it with patients. There is a lot of avoidance of spelling things out plainly to people who are avoiding accepting it themselves. Even some doctors and nurses who work in HOSPICE, whose jobs are all about helping dying patients die, sometimes push too far to keep people on the alive side of things even if it means prolonging discomfort.

I can’t agree with your OP at all, not the ugly thread title. The truth is that the situation in American medicine is overwhelmingly the flip side of the coin - we spend astronomically to keep people alive in the final years or months, and often causing much anguish in the process for patients and families alike. All because we can’t talk about death in this country and most folks are terrified of it.

As to your parents OP - this is a well tread area of medical ethics and not some ageism bias of the doctors. When patients are in their 80s and beyond, they are statistically much less likely to fully recover from many procedures and treatments - exponentially less likely than a patient in their 50s, 60s, or even 70s. Same with their statistical likelihood of experiencing complications which hasten greater disability and/or death.

This factors into the physician’s determination of what is in the best interests of the patient, and no doctor is required to perform a surgery or treatment on a patient if they feel it is going against their best interests. Some doctors are skilled at explaining this and others just hem and haw and avoid flat out saying how things are. It has nothing to do with a lack of caring about your loved one. I would argue that there is more caring on offer from someone who nudges you in the direction of recognizing your impending mortality than in steering you toward further denial.

The patient alone determines what is best for them. Physicians may be learned intermediaries but they have no right to decide whether a patient gets treatment or not. They have a duty to explain all options and the likely results of each. If they can’t do that, they should switch to pathology.

Not everyone who resists being “nudged” toward the beyond is in denial. Some just have more hope than the people doing the nudging.

No, patients don’t dictate their care. You can’t just order a doctor to do this or that, if it’s not medically indicated. No wonder so many people are leaving the medical field. You think you can boss them around like they’re your nanny.

While medical arrogance may know no boundaries, it is the physician’s duty to explain options and associated prognoses. Failure to do so is prima facie negligence. What is “medically indicated” is a matter of opinion, and patients have a right to have that opinion and the grounds for it made clear. Hiring a physician to provide services does not create a custodial relationship where the physician holds the power of life and death to be exercised at his or her caprice. Oh, and I don’t “think” I can boss the Great Exalted around, I know I can, and I do.

Ooh, big talk. Sorry, no doctor is going to perform any procedure that they think is unjustified. Well, maybe your shitty one, but then you have a shitty doc. So there’s that. And I’m laughing at you thinking you know better than a doctor what’s medically indicated. Where did you get your MD?

They may not know more medically but they sure as heck know a lot about how doctors view, value, and correspondingly treat their Black patients.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I think in an ideal world doctors could give their all to everyone. The reality is they are understaffed, very overworked and many are burned out. Since they are not superhuman, would you rather a doctor give more attention to a mother or father with children at home, one of whom may have special needs or medical issues or emotional struggles or put all their energy into giving your elderly parent a few more months?

DP, but obviously my parents are more important to me than some random stranger’s kids. Let’s not start moving eugenics-ward, shall we?

Sure, but you’re kind of shitty if you’d rather your elderly parents have 3 more years of life than a 20 year old have another 50-60.

You are a ghoul.

I am sorry to have to bring the bad news, but demographics in this country and virtually everywhere in the advanced world means that we won't be able to offer extraordinary life saving measures to everyone who wants it. We won't have enough labor to provide aging care for the old but not dying. Or child care to the young. Or a lot of other things. Get used to it--it's coming.

Anonymous wrote:Geez, who cares about *possibly* resentful medical staff, when your own child is cursing your existence.

Your piss poor attitude doesn’t come from your parents. God forbid, they want to eat ice cream and watch birds.

I'm sad to say that isn't what we are talking about. Intervention is great when it leads to birds and ice cream.

Unfortunately -- and I don't mean this flippantly -- there aren't any windows in the ICU, and they don't give you ice cream through a tube.

Geez, who cares about *possibly* resentful medical staff, when your own child is cursing your existence.

Your piss poor attitude doesn’t come from your parents. God forbid, they want to eat ice cream and watch birds.

Anonymous wrote:I’ve actually heard from a few people that even those who don’t want to be saved end up being saved against their wishes. I thought the bias was the opposite actually

It is.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Absolutely terrible thread title, BTW.

Agreed, it is a disgusting title.

I am an attorney who changed careers and have been working in mostly hospice care for the last near decade. The majority of my patients have been elderly, but some were DNR based on chronic degenerative conditions at younger ages.

I’ve noticed that the majority of doctors are just as uncomfortable as the average person with having conversations about death. They may be more matter of fact about it in their own thinking, but they don’t really want to talk about it with patients. There is a lot of avoidance of spelling things out plainly to people who are avoiding accepting it themselves. Even some doctors and nurses who work in HOSPICE, whose jobs are all about helping dying patients die, sometimes push too far to keep people on the alive side of things even if it means prolonging discomfort.

I can’t agree with your OP at all, not the ugly thread title. The truth is that the situation in American medicine is overwhelmingly the flip side of the coin - we spend astronomically to keep people alive in the final years or months, and often causing much anguish in the process for patients and families alike. All because we can’t talk about death in this country and most folks are terrified of it.

As to your parents OP - this is a well tread area of medical ethics and not some ageism bias of the doctors. When patients are in their 80s and beyond, they are statistically much less likely to fully recover from many procedures and treatments - exponentially less likely than a patient in their 50s, 60s, or even 70s. Same with their statistical likelihood of experiencing complications which hasten greater disability and/or death.

This factors into the physician’s determination of what is in the best interests of the patient, and no doctor is required to perform a surgery or treatment on a patient if they feel it is going against their best interests. Some doctors are skilled at explaining this and others just hem and haw and avoid flat out saying how things are. It has nothing to do with a lack of caring about your loved one. I would argue that there is more caring on offer from someone who nudges you in the direction of recognizing your impending mortality than in steering you toward further denial.

The patient alone determines what is best for them. Physicians may be learned intermediaries but they have no right to decide whether a patient gets treatment or not. They have a duty to explain all options and the likely results of each. If they can’t do that, they should switch to pathology.

Not everyone who resists being “nudged” toward the beyond is in denial. Some just have more hope than the people doing the nudging.

No, patients don’t dictate their care. You can’t just order a doctor to do this or that, if it’s not medically indicated. No wonder so many people are leaving the medical field. You think you can boss them around like they’re your nanny.

While medical arrogance may know no boundaries, it is the physician’s duty to explain options and associated prognoses. Failure to do so is prima facie negligence. What is “medically indicated” is a matter of opinion, and patients have a right to have that opinion and the grounds for it made clear. Hiring a physician to provide services does not create a custodial relationship where the physician holds the power of life and death to be exercised at his or her caprice. Oh, and I don’t “think” I can boss the Great Exalted around, I know I can, and I do.

Ooh, big talk. Sorry, no doctor is going to perform any procedure that they think is unjustified. Well, maybe your shitty one, but then you have a shitty doc. So there’s that. And I’m laughing at you thinking you know better than a doctor what’s medically indicated. Where did you get your MD?

Anonymous wrote:Thank you doctor for this important comment.

I am the attorney turned hospice practitioner and am also a onetime premed zoology student who interned at a regional hospital’s oncology center. I’ve continued to be a reader of science and particularly medical science since my path changed decades ago, and my inclination toward medicine is what brought me to hospice care.

I have attended dozens of deaths in hospice and a few in my own family as well. I have very clear views about how I will respond to any number of diagnoses I might encounter as I age. I have a detailed living will and a medical POA I trust wholeheartedly. I have every intention to die like a doctor.

When I was practicing law for a short time before bailing I ran a solo practice in a small country town in rural America. When I opened up I had many clients come in for estate planning and I made it my practice to offer free preparation of living wills/medical directives to them, and eventually I extended that offer to all my clients whether family law, criminal, civil etc. I would say close to 75% deferred my offer to provide this service.

Americans have a very hard time contemplating death and planning for it. Most have no estate planning in place even if they have children. The vast majority do not have advanced medical directives with end of life wishes established. This is exactly why our healthcare system is crippled by exorbitantly costly end of life care AND why so many families have very negative experiences of losing a grandparent or parent in a hospitalised, medicalised death that is clinical and sadly often cold.

Greetings and thanks back to you. Thank you for doing the hard work, and thank you for staying in the play. Hospice has so much that is rewarding, and it can also tear right through you. Keep taking care of yourself, okay?

Thank you doctor for this important comment.

I am the attorney turned hospice practitioner and am also a onetime premed zoology student who interned at a regional hospital’s oncology center. I’ve continued to be a reader of science and particularly medical science since my path changed decades ago, and my inclination toward medicine is what brought me to hospice care.

I have attended dozens of deaths in hospice and a few in my own family as well. I have very clear views about how I will respond to any number of diagnoses I might encounter as I age. I have a detailed living will and a medical POA I trust wholeheartedly. I have every intention to die like a doctor.

When I was practicing law for a short time before bailing I ran a solo practice in a small country town in rural America. When I opened up I had many clients come in for estate planning and I made it my practice to offer free preparation of living wills/medical directives to them, and eventually I extended that offer to all my clients whether family law, criminal, civil etc. I would say close to 75% deferred my offer to provide this service.

Americans have a very hard time contemplating death and planning for it. Most have no estate planning in place even if they have children. The vast majority do not have advanced medical directives with end of life wishes established. This is exactly why our healthcare system is crippled by exorbitantly costly end of life care AND why so many families have very negative experiences of losing a grandparent or parent in a hospitalised, medicalised death that is clinical and sadly often cold.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Absolutely terrible thread title, BTW.

Agreed, it is a disgusting title.

I am an attorney who changed careers and have been working in mostly hospice care for the last near decade. The majority of my patients have been elderly, but some were DNR based on chronic degenerative conditions at younger ages.

I’ve noticed that the majority of doctors are just as uncomfortable as the average person with having conversations about death. They may be more matter of fact about it in their own thinking, but they don’t really want to talk about it with patients. There is a lot of avoidance of spelling things out plainly to people who are avoiding accepting it themselves. Even some doctors and nurses who work in HOSPICE, whose jobs are all about helping dying patients die, sometimes push too far to keep people on the alive side of things even if it means prolonging discomfort.

I can’t agree with your OP at all, not the ugly thread title. The truth is that the situation in American medicine is overwhelmingly the flip side of the coin - we spend astronomically to keep people alive in the final years or months, and often causing much anguish in the process for patients and families alike. All because we can’t talk about death in this country and most folks are terrified of it.

As to your parents OP - this is a well tread area of medical ethics and not some ageism bias of the doctors. When patients are in their 80s and beyond, they are statistically much less likely to fully recover from many procedures and treatments - exponentially less likely than a patient in their 50s, 60s, or even 70s. Same with their statistical likelihood of experiencing complications which hasten greater disability and/or death.

This factors into the physician’s determination of what is in the best interests of the patient, and no doctor is required to perform a surgery or treatment on a patient if they feel it is going against their best interests. Some doctors are skilled at explaining this and others just hem and haw and avoid flat out saying how things are. It has nothing to do with a lack of caring about your loved one. I would argue that there is more caring on offer from someone who nudges you in the direction of recognizing your impending mortality than in steering you toward further denial.

The patient alone determines what is best for them. Physicians may be learned intermediaries but they have no right to decide whether a patient gets treatment or not. They have a duty to explain all options and the likely results of each. If they can’t do that, they should switch to pathology.

Not everyone who resists being “nudged” toward the beyond is in denial. Some just have more hope than the people doing the nudging.

No, patients don’t dictate their care. You can’t just order a doctor to do this or that, if it’s not medically indicated. No wonder so many people are leaving the medical field. You think you can boss them around like they’re your nanny.

While medical arrogance may know no boundaries, it is the physician’s duty to explain options and associated prognoses. Failure to do so is prima facie negligence. What is “medically indicated” is a matter of opinion, and patients have a right to have that opinion and the grounds for it made clear. Hiring a physician to provide services does not create a custodial relationship where the physician holds the power of life and death to be exercised at his or her caprice. Oh, and I don’t “think” I can boss the Great Exalted around, I know I can, and I do.

You can certainly shop around to find someone to do what you want, if you can find someone to do it. You can't force a doctor to do what you want, if they do not believe it is indicated. You just can't. That's the nature of a profession with a professional license.

Sure, maybe they humor you if you want to "boss the Great Exalted around," if what you want remains within the standard of care, but that's not the same. They are in charge of them. You are in charge of you. If you are able to make decisions for yourself, then nobody can force you to do anything. But you also can't force them -- both sides have autonomy.

Don't forget about this:
1. 2011, How Doctors Die: https://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/
2. 2015, How doctors want to die is different than most people: https://www.cnn.com/2015/08/10/health/how-doctors-want-to-die/index.html

"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."

I'm the doctor above who talked about breaking ribs giving CPR. I still hate that feeling under my hands. You don't forget it.

All the docs I know have plans about this. The ones I've discussed it with have identified someone close, usually a colleague, to make absolutely sure extraordinary measures aren't taken in the wrong circumstances. I'm currently in my 50s and have a chronic congenital cardiac condition. I think about this a lot, actually.

Am I okay with someone making a different decision? Absolutely. I defend your autonomy, too, even when you are not able to for yourself. I try to make sure I know your wishes and follow them if I can. I did this for my mother as she was dying, too, as I had medical power of attorney and knew she wanted every chance.

But no, you can't bully me when it's not good care. That's not because I'm exalted; it's because I have a license to protect. I didn't accept money under the table to circumcise a grandfather (WTF, and you are also now banned from my clinic), and I don't get bullied into prescribing addictive drugs just because you want them, and I don't participate in pill farms or anything but the same daily slog through doing the hard work and engaging in shared decision-making with people trying to do their best as we work together on it.

However, I'm likely not going to die like you do. Neither are most of my colleagues. That might not change your mind, and I respect that. But you should know it.

And I totally disagree with you. I think American health care goes overboard in interventions and I think heavy interventions in old age are damaging to quality of life and ridiculously expensive for our health care system and society.

+1 - and I have been around healthcare in two other countries. I have worked in US nursing homes and hospice.

People should talk about what the want Re: end of life care. This is not propaganda to increase profits. It is a hard decision and easier on everyone of the patient’s perspective in known. It is hard for family and healthcare workers to even passively allow death to occur.

Anonymous wrote:

Anonymous wrote:Eating ice cream and watching the birds would be fine.

How about being limited to a feeding tube and having your daily activities consisting of being moved to prevent bedsores?

I have known people in that shape and worse who had no interest in dying and were still glad to wake up in the morning.

Haha They could still watch Netflix! Silver linings!