Guess what? We're all going to die. And someone apparently leaked the news to the government. In a startling announcement this week, Medicare has decided to pay doctors to talk about the "D" word, more pleasantly called "end-of'-life." Not a moment too soon, with 55 million Medicare beneficiaries headed to the Big Woodstock in the Sky.
What's the big deal? The way I see it, physicians can now invoice Medicare to actually discuss the inevitable with their patients. You know, get paid for what was already their job. But death, oddly enough, isn't something doctors are taught or skilled at discussing. So a little reimbursement is the carrot that will nudge them to deal with reality.
Why is it so hard for doctors--or any of us--to talk about how we want our lives to end? We chat about it casually: "No extra measures for me." "I don't want to be a vegetable." "When it's my time, let me go." But when that day actually does come, for many people, medicine prevails. One more round of antibiotics, let's continue the chemo, there's a new treatment that has shown promise. Doctors peddle hope and many of us leap at the offer. For what? So we don't have to admit the truth and say good-bye.
But what about the person who is actually dying? You may be surprised to learn that they know their life is ending and they have come to terms with it. Consider The Death of Ivan Ilyich, by Tolstoy. Ivan is a 45 year-old man in good health, until he falls off a stepladder. The pain in his side grows worse, he continues to decline, and then he can't walk. Suddenly, the “intelligent, polished, lively, and agreeable man” is incapacitated. His depression grows as friends avoid him and a string of doctors try every treatment known...and a few unknown. Ivan grows furious at the futile remedies: “What tortured Ivan Ilyich most,” Tolstoy writes, “was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result."
Ivan knew he was dying, but his greatest pain? That no one would acknowledge it and care for him as a person whose life was ending. No one to talk about its meaning for him and that he had mattered. To ask if there was anything he still needed to do or say. To find out what he wanted in his final days. To just sit with him and hold his hand. To tell him he was loved.
It's easy to say, well, that's just how doctors are. They train in a "culture of cure" and that to accept death is to admit failure. I simply don't buy that. Every physician sees plenty of patients die. So why do they dance around it? Partly, it's easier to keep tossing out options; that way, you can say "We tried everything" and everyone--at the least the doctor and the family--feels better. Mostly, it's a necessary self-defense mechanism that allows doctors to function in an occupation that deals with heartbreaking sickness and tragedy every single day. When they're done with work, just like the rest of us, they go home and make spaghetti, give the kids baths, and talk about getting that new furnace installed before winter. After all, they're human, too.
Do doctors think about their own deaths? You bet. And in a fascinating article, "How Doctors Die," Ken Murray, MD, tells us that physicians choose less aggressive therapies and no resuscitation. A survey done at Stanford University found that 90% of doctors facing death decline treatment and choose to die at home.
So. It's good that end-of-life discussions will be happening more often. But even better? Make your own plan--and make sure your family knows. Have "the talk" now. Today. Don't put others in the awkward position of deciding how you exit this world.
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