The G-Spot: A Good Death

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Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light.

-Dylan Thomas

As organisms that fight for survival, just as other organisms on the plant, a fear of death is built into our psyche. We write about it, we sing about, and Woody Allen obsesses about it. Throughout the ages, civilizations have created various deities to try to explain our origin, our purpose, and our fates when our bodies fail us. As science has evolved, we have learned to worship technology as a new deity that may protect us from aging and our ultimate demise. Despite our growing medical technology, life still has a 100-percent mortality rate. Someday, you are going to die.

Our medical technology sometimes gives us false hope. We pray to the false gods of machines and newer and more expensive pharmaceuticals to stay our execution, often without the thinking about the financial and emotional costs. As a society, we need to be good stewards of resources, as these resources are not infinite. Money that is spent on futile health care could be better used for other things such as alleviating homelessness, treatment for substance use disorder, or perhaps ensuring that every American has a cell phone. What is often overlooked in this discussion is the burden of suffering.

When you are admitted to the hospital, you will often be asked your wishes as far as resuscitation. If you are a 46- year-old otherwise healthy person who is having a heart attack, the answer will almost always be to do everything possible to resuscitate you. If you are 102 years old with dementia and a massive stroke, the answer will probably be to allow natural death. In fact, if I’m the doctor for the latter, I would not ask the family their wishes; I would tell them that it would be medically futile to attempt resuscitation and would only prolong suffering.

In discussing the end of life, the trend over many decades has been toward less paternalism and more autonomy. We encourage living wills and we try to discuss these issues with patients ahead of time. When I was a medical student in an academic university, the discussion was never IF we were going to resuscitate, but what fluids, what size endotracheal tube, and how many medical students could practice procedures before we called the code. Now we are trying more to give the patients and families their opportunity to decide within the setting of their values.

One of the ethical dilemmas in medicine is the balance between autonomy and beneficence. In the United States, we greatly value autonomy in medical decision-making; your ability to make your own decisions about your life, including health care. Built into Western medicine is the idea of informed consent. I offer you medical options and you can choose to take a medication, undergo a procedure, or try your favorite essential oil. I inform you of the options, and make recommendations, but autonomy says that you get to decide if you prefer lavender or vanilla.

Beneficence is a stronger force in other cultures, but it is also ingrained in our medical culture. Beneficence is essentially when your clinician is deciding what is best for you. The opposite is maleficence, the act of committing harm, which every physician swears an oath not to do. If there was no beneficence in medicine, you could walk into your neighborhood pharmacy and get OxyContin, Adderall, Xanax, and a side of cocaine by request. I practice beneficence over autonomy regularly by telling patients that certain controlled substances are not in their best interest, or declining a patient’s request for an unnecessary CT scan because the risks of radiation outweigh potential benefits. It is also beneficence when I place a patient on a psychiatric hold because I feel that they are in imminent danger of harming themselves.

When discussing end of life care with patients, health-care professionals must balance these two ideas. Many providers are uncomfortable with these discussions, and often begin and end the discussion with, “Do you want everything done?”

Well, who doesn’t want everything done? The logical converse is putting someone in a corner to be ignored as they gasp for breath. In reality, there is plenty that can be done at the end of life. Medical school focuses on the diagnosis and treatment of disease, but often falls short in discussions of palliation of symptoms. I do not like the term “do not resuscitate (DNR)” as it implies that we are withholding care. In fact, what we are doing is changing to focus of care to allow natural death and palliation of pain and anxiety. We have many treatments available for symptoms at the end of life and I minimize the suffering of my dying patients.

What happens when the family and the provider are not on the same page? Just like most areas of human interaction, the key is communication. I was the chair of the bioethics committee at a community hospital for two years and the vast majority of ethics consultations were regarding end of life care. In almost all of these cases, the issue was resolved by compassionate, open communication. Physicians are often frustrated by patients and families who have unrealistic expectations. Unfortunately, we also put the burden on families in the name of autonomy. I have seen many families struggle with the decision of whether or not to attempt resuscitation for a loved one, and it is evident that they fear the guilt of making the wrong decision. I often then put that burden on myself and give them an opportunity to object by saying things such as, “resuscitation is unlikely to provide a meaningful recovery and likely to cause suffering so I recommend if she stops breathing or her heart stops that we allow a natural death.”

This often assuages the family’s guilt as I advise them what I think is best.

Since death is inevitable, the decision is really the balance between extending quality life and suffering. If I extend your life, but during that time you are unable to communicate and have to endure painful procedures, I have not really helped you. However, if those painful procedures will then return you to a life that you consider meaningful, I have done some good. Although I cannot see the future, I can predict the likelihood of a good outcome based on your prior health, function, and the nature of your current illness. All too often I see someone with severe dementia who is bed-bound with a feeding tube undergoing painful procedures that will inevitably only prolong suffering. Ethically, I think that is doing harm.

According to medical ethics, clinicians should not offer futile care. I see it happen in the name of autonomy or misguided fears of litigation. I do not offer feeding tubes to patients with dementia who stop eating because there is ample evidence that it does not prolong life and it does increase suffering. Those of us in healthcare need to remember that we are the experts and we should first do no harm. Those of you who are involved in these decisions need to ask your medical providers these difficult questions. Ask your physician, “If this were your mother, what would you do?”

Most of the deaths I see are predictable. As we age and deal with illness, we should not fear death, but plan for it. Death is a natural part of life, and will occur whether we are ready to accept it or not. Several studies have demonstrated that physicians are more likely to die at home and less likely to have aggressive surgical procedures at the end of life. Our patients should have the same consideration and be allowed a dignified death.

Speak with your family about your wishes and their wishes. If you have a family member with a serious chronic illness, don’t wait until you’re in the emergency department and frightened and someone is asking you if they should “do everything”.

We will all die some day and if we are prepared, we may be able to die well.

Greg Greenberg
Greg Greenberg grew up in Santa Monica, California. After undergraduate training at UCLA he attended medical school at Ohio State University and completed a residency in family medicine in Columbus, Ohio. He moved to Redding after residency in 2004 and has served the Redding community as a family physician, hospitalist, emergency physician, and, most recently, in addiction medicine. When he’s not enjoying the calm atmosphere of the emergency department he enjoys the chaos of being a full-time parent as well.
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17 Responses

  1. Randall R Smith Randall R Smith says:

    First Nation Inuit had a much better understanding and societal demonstration of “carrying capacity” than supposedly advanced modern day Americans. We desperately need more than individual advance directives and our lack of addressing this matter is more serious with the passage of time. Appreciation is sent to those still in the trenches.

  2. Avatar Beverly Stafford says:

    Excellent article. I was talking with a woman who was seething because the physician attending her elderly, ill, bedridden, and dying mother had called for a mammogram. It’s idiocy like that that makes lay people question the connection between the medical and insurance fields.

  3. Avatar Tim says:

    “I do not observe professional boundaries. My doctor constantly writes, PSA test, prostate specific antigen, and I just cross it out. And he says, ‘What the hell are you doing? Why are you doing this?’ And I say, ‘Well I don’t want to give you an opportunity to do something dumb. If I’ve got an unfixable cancer that’s growing fast in my prostate I’d like to find out 3 months in the future, not right now. And if I got one that’s growing slowly, I don’t want to encourage a doctor to do something dumb and intervene with it. So I just cross it out.’ Most people are not crossing out their doctor’s prescriptions, but I think I know better.” — Charles Munger (93)

  4. Avatar John Englert says:

    I thought your article well reasoned and credibly written. Your first hand experiences as a healthcare professional also add experiences not available to most. I have had, and have dealt with DNRs, for many years myself as an insurance professional and caring advisor. So many variables impact these thoughts and decisions – such as religious beliefs, familial dynamics and needs, personal preparedness, and so much more. I am convinced that while this may seem rather straight forward in its specifics will remain a deeply personal and individual decision process as it should. Life IS precious. Thank you for your thoughts here.

  5. Avatar Richard Christoph says:

    Informative, poignant, and beautifully written.

  6. Avatar Louise Hanson says:

    Thank you, Dr. Greenberg for an excellent article. I had the opportunity and privilege of working for several years as a hospital chaplain and had many discussions with patients and families regarding end of life care and wishes. As a crises chaplain, I witnessed many times when families struggled to make decisions of what to do when a crises arose with their loved one; too often these family members would not agree as to what to do and the patient had never discussed their wishes with the family. Also, too often a physician would come in to inform the family about the crises, would want to know what they wanted done and then leave, often not asking if the family had questions or needed clarification. As a chaplain with a nursing background and education in medical ethics, I would try to interpret for them what the physician had said and if I couldn’t, or were uncomfortable doing so, I would attempt to get the physician to come back to explain further and answer questions. At times, if the physician had not already left, they would grudgingly agree to go back to the family. And, physicians, when interacting with the family, please sit down if at all possible, just don’t stand or lean on the wall with your arms crossed; it signals to the family that you are rushed or in a hurry, often causing them to be reluctant to ask questions or for clarification.

    Besides working with and supporting patients, families, hospital staff, and physicians, I was very involved in working with the family practice residents during their 3-year residency, helping them to learn about and integrate pastoral care into their care of their patients. I am a firm believer that all medical schools should have at least a semester of pastoral care as part of their curriculum. I also believe that all hospitals and clinics should have a well staffed full-time pastoral care department who would be available for patients, families, staff, and physicians. Many of the available hospital pastoral care departments don’t recognize that staff and physicians also need pastoral care at times.

  7. Avatar brad maloney says:

    I just returned home a couple weeks ago after having been in the Sacramento area over three weeks. I was advocating for my stepmother who had been in the hospital fighting a losing battle with an infection. She had her “Health Care Directive” and “DNR” in place and we went back over it at couple of different stages of the process. Still, it got complicated. I found myself frustrated and upset with my lack of experience on how to deal with the situation and with what seemed like hedging by the doctors. I knew there was no way she was winning this fight and I felt they had to know too but I couldn’t get them to come out and say it. They wanted to keep “treating” her, with the outside chance that this 80lb 87 year old woman was going to beat some impossible odds. Three days before she passed, the Palliative Care Nurse showed up and started talking some sense, albeit with kit gloves. What we needed was for the “professionals” to lay out the true cost and benefit of her care and it didn’t happen until the day before she passed. By then, it was too late. She passed with not near enough Palliative care and I’m still dealing with the regret of having not been able to do more for her. I’m sorry if this is TMI for some folks but write to help drive home Greg’s point that even though my stepmother thought she had her ducks in a row for end of life treatment, she still suffered needlessly. Greg, thank you so much for your article, your patients are fortunate to have you as their physician.

  8. Avatar Cory Bonney says:

    Having knocked on Deaths Door and the door not opening, I now have all legalities spelled out and am beyond grateful to Dr. G for helping me regain my health. Keep being you Greenie- you’re amazing!

  9. Avatar Greg greenberg says:

    Thanks for all of the positive comments. I also have to mention Dr. Ron Sand who is an incredibly good and caring physician who does palliative care in our community.

  10. Avatar Gilman says:

    Thank you Greg. Another thought provoking article excellently written. Peace.

  11. Avatar Mary Beaver says:

    Very well written! It’s such a difficult discussion for families . Growing up with a Mom who was a nurse she dealt with this daily. I am the youngest of four but when my Parents did their advance directive it was me they put in charge of medical decisions. My Mom knew with my medical experience I wouldn’t prolong life if that was a decision that had to be made. I did have to use it and am glad I could do right by my Mom. Keep up the good work Greenie.

  12. Avatar Joanne Lobeski Snyder says:

    Thank you Dr. Greenburg for this extraordinary article. I’ve been a medical advocate for a couple older friends and have witnessed compassionate, honest advice and care, and disinterested “assembly line” treatment of an elder. You’ve shared information that most non-medical people might not have considered. Again, thank you.

  13. What a powerful, important column, followed by such meaningful, heartfelt comments. Thank you, Dr. Greenberg, for opening the door to this crucial conversation.

  14. Avatar AJ says:

    As I advance into my 80s, I’ve made a point to not only discuss this with my kids but also to write it down and have it notarized. No heroic measures, (and there’s still too much wiggle room there for my taste). Keep me comfortable and hydrated and hold my hand.
    I wish there were someway to take the mystery out of death. It’s not so much a fear of the actual event, but the very natural fear of the unknown. If only Houdini had actually made it back as he had promised.
    Thanks for the very much needed and informative article.

    • Avatar Sandie says:

      Sadly, I found out the hard way that there is a procedure called “Care and comfort”…It affords you the comfort of oxygen, hydration, etc., while not technically keeping you mechanically alive. AJ, tell your children of this option…it’s something we all need at our time of passing. Of course, I’m hoping you are going strong for many more years!!!

  15. Avatar Sandie says:

    My dad had a DNR order during and after his heart surgery….he was 82 and did NOT want to be kept alive by mechanical means if he was not able to be alive on his own. A well known heart surgeon (has since retired) took it upon himself to not only disregard my dad’s wishes but to also do another invasive procedure on him. My question is…When is a DNR not enough? Why can a doctor override his wishes?

  16. Avatar Tom says:

    When my time comes, Greg, no matter what Mrs C says, you keep me alive. Put my head in a jar if you must, and store it in a cold place in the cellar. I will not go gentle. 😉

    I’ve been reading a lot of Harari lately, after years of reading the likes of Kurzweil, and I like what he says about the end: death is just a technical problem, and the engineers are currently working it out.

    Although he doesn’t believe we’ll achieve endless life by the end of the century (Kurzweil does), he does think that by 2050 we should have worked out how to continue “one decade at a time,” for those with the desire and means. I’ve got half that equation solved.

    Assuming I make it til ’50.

    Another good read, and good thoughts on our finality. I wasn’t aware of the term “beneficence” before now, but I can’t imagine there is any other way to ethically practice medicine. Keep up the great work, pal, here and there. 🙂