Topic: When doctors face death, they don't fight it as hard

[LongTimeListener]

http://online.wsj.com/article/SB10001424052970203918304577243321242833962.html

Very interesting article from a retired USC professor about how doctors react differently to care decisions when they are elderly and facing life-threatening problems. For the most part, they decline aggressive treatments that have a small chance of success, whereas the general population tends to try anything and everything they can to hang on a little bit longer. The writer says it's because doctors know too much -- they've seen how low the chances are and especially the pain that the patient has to go through in the often futile quest to beat the odds.

This struck me:

During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right). ...

Why such a large gap between the decisions of doctors and patients? The case of CPR is instructive. A study by Susan Diem and others of how CPR is portrayed on TV found that it was successful in 75% of the cases and that 67% of the TV patients went home. In reality, a 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived for more than one month. Of these, only about 3% could lead a mostly normal life.

This touches on Palin's infamous "death panels" and such, but having had two recent experiences with elderly folks on end-of-life and having gotten advice from a couple of our doctor friends who weren't involved in the case, it certainly rings true that our doctor friends were far more at ease telling us it's over and/or fighting would just be too painful. Combined with costs that can easily approach $500,000 just for that last bit of life, it's going to be a hot button in coming years.

[TigerVols]

Only 3 percent of people who EVER have CPR survive to lead a normal life? Or 3 percent of end-of-life patients?

Edit: OK, I read the story (it's not behind the paywall) and my question's answer is unclear.

I survived CPR, and knew I was lucky but just didn't know I was THAT lucky!

[LongTimeListener]

Yeah, I take that to mean of the 95,000 cases studied, CPR works for 7,600, and only 3 percent of that (228) live a normal life. I don't know if I'm correct on that, maybe it is 3 percent of the initial 95,000, and I don't know how they define normal. But really the fact that only 8 percent survive is pretty staggering based on the image we have.

[The Big Ragu]

I understand why there is a misperception about CPR success rates, based on what gets portrayed on TV.

But if you think about it, it shouldn't be surprising that people who have CPR performed on them end up dead or with brain damage most of the time. If you are performing CPR, it means someone's heart has stopped. That's a really bad thing. And even if the CPR works, it doesn't restart the heart--it gets enough blood to the brain and heart to delay tissue death. If you buy enough time, maybe a defibrillation gets the heart going again, if you are really lucky. But at best, the CPR itself just buys time.

[doctorquant]

Only 3 percent of people who EVER have CPR survive to lead a normal life? Or 3 percent of end-of-life patients?

Edit: OK, I read the story (it's not behind the paywall) and my question's answer is unclear.

I survived CPR, and new I was lucky but just didn't know I was THAT lucky!

Sounds like the article's saying you were one of the 0.24% ...

[Stitch]

http://online.wsj.com/article/SB10001424052970203918304577243321242833962.html

Very interesting article from a retired USC professor about how doctors react differently to care decisions when they are elderly and facing life-threatening problems. For the most part, they decline aggressive treatments that have a small chance of success, whereas the general population tends to try anything and everything they can to hang on a little bit longer. The writer says it's because doctors know too much -- they've seen how low the chances are and especially the pain that the patient has to go through in the often futile quest to beat the odds.

This struck me:

During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right). ...

Why such a large gap between the decisions of doctors and patients? The case of CPR is instructive. A study by Susan Diem and others of how CPR is portrayed on TV found that it was successful in 75% of the cases and that 67% of the TV patients went home. In reality, a 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived for more than one month. Of these, only about 3% could lead a mostly normal life.

This touches on Palin's infamous "death panels" and such, but having had two recent experiences with elderly folks on end-of-life and having gotten advice from a couple of our doctor friends who weren't involved in the case, it certainly rings true that our doctor friends were far more at ease telling us it's over and/or fighting would just be too painful. Combined with costs that can easily approach $500,000 just for that last bit of life, it's going to be a hot button in coming years.

At some point, families have to let go of older family members. It seems harsh, but extending life for someone over 70 seems to be cruel to the patient. I need to get a health directive drawn up detailing what I'd like to happen. Right now, try to keep me alive. Once I reach 65, just do something for pain, but otherwise let me die.

[TigerVols]

Only 3 percent of people who EVER have CPR survive to lead a normal life? Or 3 percent of end-of-life patients?

Edit: OK, I read the story (it's not behind the paywall) and my question's answer is unclear.

I survived CPR, and new I was lucky but just didn't know I was THAT lucky!

Sounds like the article's saying you were one of the 0.24% ...

I think so; and ever since, my luck's been pretty damn bad so I think I used it up all on that day.

[/no complaints!]

[jr/shotglass]

At some point, families have to let go of older family members. It seems harsh, but extending life for someone over 70 seems to be cruel to the patient. I need to get a health directive drawn up detailing what I'd like to happen. Right now, try to keep me alive. Once I reach 65, just do something for pain, but otherwise let me die.

Personally, I think I'd want to skew those numbers closer to over 80.

[Dyno]

At some point, families have to let go of older family members. It seems harsh, but extending life for someone over 70 seems to be cruel to the patient. I need to get a health directive drawn up detailing what I'd like to happen. Right now, try to keep me alive. Once I reach 65, just do something for pain, but otherwise let me die.

Personally, I think I'd want to skew those numbers closer to over 80.

For sure.  65 is not very old.  My dad was 68 when he had a kidney transplant.  He still went to the office six days a week and served on numerous volunteer boards for years after that.  Is Stitch saying we should have just given him some Tylenol and said goodbye? 

[LongTimeListener]

I don't know that it's so much about age as it is the particular health condition. The lead anecdote in the article focused on a 68-year-old man diagnosed with pancreatic cancer, and he could take the treatments and prolong his life for five years during which he'd be miserable and unable to do anything. A kidney transplant would be a completely different prognosis.

Put another way, based on this article, I'd guess most doctors would never have let themselves go through what Steve Jobs went through. And Jobs was in his early 50s when he was diagnosed.

[Stitch]

At some point, families have to let go of older family members. It seems harsh, but extending life for someone over 70 seems to be cruel to the patient. I need to get a health directive drawn up detailing what I'd like to happen. Right now, try to keep me alive. Once I reach 65, just do something for pain, but otherwise let me die.

Personally, I think I'd want to skew those numbers closer to over 80.

For sure.  65 is not very old.  My dad was 68 when he had a kidney transplant.  He still went to the office six days a week and served on numerous volunteer boards for years after that.  Is Stitch saying we should have just given him some Tylenol and said goodbye? 

I'm guessing your dad didn't have an issue with getting a transplant. It seems it's  important to have a health directive in place so your family doesn't have to make these decisions.

At some point, especially since we don't have single-payer insurance in the U.S., there will be limits put in place by insurance companies on end-of-life care. The death panels will come from an insurance company committee.

[typefitter]

I understand why there is a misperception about CPR success rates, based on what gets portrayed on TV.

But if you think about it, it shouldn't be surprising that people who have CPR performed on them end up dead or with brain damage most of the time. If you are performing CPR, it means someone's heart has stopped. That's a really bad thing. And even if the CPR works, it doesn't restart the heart--it gets enough blood to the brain and heart to delay tissue death. If you buy enough time, maybe a defibrillation gets the heart going again, if you are really lucky. But at best, the CPR itself just buys time.

This is right. The myth of CPR is that it restarts hearts. Shock doesn't restart hearts, either; only some serious toxic medications will restart a stopped heart. (Those paddles are used for a different kind of heart attack, when your heart starts beating too fast; they reset the rhythm.) With CPR, you're just (doing a very poor job of) replacing the heart that's stopped. At its best, CPR gives you 16 percent of the stroke volume that the heart gives you. And the problem with brain tissue is that, when it's deprived of oxygen, it dies, and there is no way to bring dead brain tissue back to life. It's gone.

CPR's really important, because that small percentage of people who do survive would have died without it. But it's going to be a small percentage, because the CPR often comes too late, or at least too late to prevent the real damage from being done.

TigerVols, if you've survived CPR, first you were unlucky—something stopped your heart—but then you were really, really lucky. Almost miracle lucky. I did a story once where I worked as a paramedic for a month. I can remember every single person who we revived, because there weren't very many.

I can also remember working on a doctor's wife at a party. She had suffered a massive heart attack. There must have been forty people in that room, watching us clatter away on her. (You want some good exercise, do CPR for ten minutes.) And the doctor just knew. He was very calm and rational about it. He'd lost his wife of, I'd guess, thirty years, and I can remember when we were at the hospital and she was pronounced officially dead, he said, "Well, that's life, you know."

[doctorquant]

At some point, families have to let go of older family members. It seems harsh, but extending life for someone over 70 seems to be cruel to the patient. I need to get a health directive drawn up detailing what I'd like to happen. Right now, try to keep me alive. Once I reach 65, just do something for pain, but otherwise let me die.

Personally, I think I'd want to skew those numbers closer to over 80.

I got my ass handed to me on the golf course last Friday by a fellow who's 72 (I'm 49 and an 11-handicapper). He wasn't buntin' it down the middle and making flukey up-and-downs, either.

[jr/shotglass]

Yeah, Stitch! Don't give me just 11 years to live!!

[YankeeFan]

Only 3 percent of people who EVER have CPR survive to lead a normal life? Or 3 percent of end-of-life patients?

Edit: OK, I read the story (it's not behind the paywall) and my question's answer is unclear.

I survived CPR, and new I was lucky but just didn't know I was THAT lucky!

Sounds like the article's saying you were one of the 0.24% ...

I think so; and ever since, my luck's been pretty damn bad so I think I used it up all on that day.

[/no complaints!]

So, are you going to tell the story. I mean, holy shit.

[YankeeFan]

So, are you going to tell the story. I mean, holy shit.

TV, hope you don't mind.

http://www.sportsjournalists.com/forum/index.php/topic,88523.msg3260281.html#msg3260281

Holy crap! I missed that when originally posted.

Quite a story. Gotta love a Good Samaritan.

[jr/shotglass]

Damn. I gotta be nicer to him.

[TigerVols]

HA!

I don't mind seeing the post dragged up if only to give thanks again to a Mr. Mike Lewis, wherever you are.

Also, despite the apparently bad results from CPR, I want to encourage everyone to take a CPR class...especially if you've not been trained in the past decade or so. It's a very different technique now.


http://www.heart.org/HEARTORG/CPRAndECC/Find-a-CPR-Class_UCM_303220_SubHomePage.jsp

http://www.redcross.org/portal/site/en/menuitem.d8aaecf214c576bf971e4cfe43181aa0/?vgnextoid=aea70c45f663b110VgnVCM10000089f0870aRCRD

[BYH]

That is a wild story, Tiger.

I once scraped my knee riding my bike. It hurt a lot. But what would you know about that?