A few months ago my 95-year-old mother reached a point where we had no choice but to move her to a nursing home. It took a few weeks for her to adjust to her new environment. Still, she calmly notes, "I have lived too long and I just want to go to sleep and not wake up." I do not doubt her honesty. She seems to have accepted the transition to her final "home," but she wishes that her death would be painless and sudden.
Last fall, my wife almost died. While she has recovered, the experience of "near-death" has extinguished her fear of dying. She tells me that had she not awakened from her coma, she would not have known any difference. She points out that there was nothing unpleasant about the experience. She wants to see our grandchildren grow older and plant more flowers in her garden, but her voice reveals no anxiety when she speaks about her inevitable death.
The attitudes of these two very different women in my life make me realize that I need to examine my attitude toward my own mortality. If they are able to accept death so easily, why do so many people fear death?
Physicians and Death
I met my cadaver the first week of medical school. This is an indelible memory for most physicians. Despite requisite lectures regarding death and respect, the initial encounter may be met with gallows humor -- a sign of everyone's anxiety. Other than gazing on my grandmother in her casket, I had never laid eyes on, much less touched, a dead human being, but I now found myself surrounded by 50 of them in the anatomy lab. This man who had donated his body to science was a tall, large-boned, African-American gentleman whose skin had yellowed slightly and seemed unnaturally wrinkled the result of the gallons of preservatives that a lab technician had pumped into his body. I never knew him when he was alive. So, I realize now that I felt somewhat disconnected from this man, his death, and the concept of my own death.
As medical students, we never cared for an individual for any length of time -- we just rotated from one service to the next. My first real experience with the death of someone I had come to know occurred during my internship. I distinctly remember Bill, a 22-year-old red-headed, clear-eyed cowboy with metastatic malignant melanoma. I can still clearly recall the layout and details from the room where he died, and how I was overcome with an unfamiliar feeling.
Today, as a neurologist, I witness people's deaths. Some are friends and family I have known for years, while others, I have never seen before their gurneys wheel into the emergency room. These experiences have shaped my personal views regarding my own death and how I might prefer to die. Because of our exposure to and understanding of how people die, physicians, at least in my experience, tend to deal with death differently than those outside of the profession.
How do physicians approach their own death? Do they make different decisions for their patients than they make for themselves? In a recent article in The Atlantic, Dr. Ira Byock, a palliative care physician, characterized the American mindset towards death as, "I don't want to think about [it] ... Our cultural tendency is to avoid serious conversations about the end of life." We fight, scream, and kill each other over the front end of life. We argue vociferously over being pro-life or pro-choice, but we put our collective heads in the sand when it is time to discuss how we want to die. Dr. Byock informs us that the "way Americans die remains a national disgrace."
Physicians often talk amongst ourselves about how we would like to die, and our decisions are strongly colored by what we have seen. We know all about futile care, misuse of intensive care units, or the prolonged use of chemotherapy and medications that fail to enhance the quality of life. Not only does our society warehouse the dead in cemeteries, but we also warehouse the dying in hospitals and nursing homes.
Many times a grieving family will demand excessive care, and our society defaults to prolonging life, but doctors usually do not choose this for themselves. In my experience, it's very common for physicians to prescribe more care for a patient than they would for themselves or their family.
Are Physicians Different?
It might seem that physicians, as knowledgeable medical professionals, would want more care than non-physicians. We have access to and education about the latest and greatest therapies. We can find out who is running the latest experimental study and maneuver our way into the test group. But, oddly enough, physicians don't die like the general public -- we tend to choose less care. We have seen one too many intensive care units filled with 85-year-olds with what we consider to be no hope of ever returning home. We have seen the horrible side effects of treatment and know that there are things worse than death. Most physicians have had a lengthy discussion with their family, and told them that they do not want any heroic measures.
A recent poll asked physicians to complete the thought, "If I or my family were faced with a terminal illness with a great potential for a terrible course and reasonable options have failed..." The respondents unanimously asked for limited interventions, and to avoid any extraordinary measures that extended life. Physicians' unique perspective allows them to enter this discussion from a different point.
Not All Physicians Are the Same
A study of 233 physicians in Israel evaluated the "Fear of Personal Death Among Physicians." It looked at physicians in the specialties of pediatrics, oncology, internal medicine, surgery and psychiatry. Prior studies had found that psychiatrists who were the least frequently exposed to death were the most anxious about their own death, followed by internists (moderate anxiety) and then surgeons, who had the greatest exposure to death (least anxious).
The physicians in Israel did not vary by specialty. Interestingly, though, physicians who had known more close friends and family who had passed expressed less fear and anxiety about dying. In other words, intimate exposure to death affects one's own perspective. As would be expected, the older physicians were less anxious about dying than the younger ones.
While this study was done in Israel and may not generalize to the United States, religious physicians had a greater personal fear of death than their non-religious colleagues. Other studies have replicated the finding that religious physicians were more frightened of punishment after death -- an interesting finding that should lead to a good deal of discussion and debate.
It Is Inevitable
As a group, physicians face end-of-life decisions more openly and have made it clear to their loved ones and peers what they do and do not want done if they become terminally ill or have little chance of a quality survival. Now it is your turn to make those same decisions, talk with your family and write your wishes down on paper. Let us know your feelings and how you plan to deal with this event that none of us can escape.
For more by Richard C. Senelick, M.D., click here.
For more on death and dying, click here.