{"id":4731,"date":"2016-06-21T00:00:00","date_gmt":"2016-06-21T06:00:00","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/2016\/06\/21\/this-hospital-life-doc-deaths-reflect-need-for-big-change\/"},"modified":"2023-08-28T11:49:27","modified_gmt":"2023-08-28T17:49:27","slug":"this-hospital-life-doc-deaths-reflect-need-for-big-change","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/this-hospital-life-doc-deaths-reflect-need-for-big-change\/","title":{"rendered":"This Hospital Life: Doc deaths reflect need for big change"},"content":{"rendered":"
<\/div>

The main idea of California family medicine physician Ken Murray\u2019s November 2011 essay, \u201cHow Doctors Die<\/a>\u201d is simple: \u201cOf course, doctors don\u2019t want to die; they want to live. But they know enough about modern medicine to know its limits,\u201d Murray wrote.<\/p>\n

Docs recognize when enough is enough, so they choose to die at home rather than pursuing painful, draining, pricey, fruitless treatments in hospitals. Murray tells poignant stories \u2013 he leads with a vignette about a physician friend who, upon learning of his pancreatic cancer, never set foot in a hospital again, living his life until cancer robbed him of it.<\/p>\n

\"\"
Stacy Fischer and Daniel Matlock, both geriatricians and palliative care physicians at University of Colorado Hospital, found that data went against the grain of intuition when it came to doctors\u2019 end-of-life decisions as compared to the rest of us.<\/figcaption><\/figure>\n

Stacy Fischer and Daniel Matlock, both geriatricians and palliative care physicians at University of Colorado Hospital, found that data went against the grain of intuition when it came to doctors\u2019 end-of-life decisions as compared to the rest of us.<\/p>\n

The story went viral and was ultimately picked up by the New York Times<\/em><\/a> and others. The work also aligned with conventional wisdom. Stacy Fischer, MD<\/a>, and Daniel Matlock, MD<\/a>, MPH, both University of Colorado School of Medicine geriatricians and palliative care specialists practicing at University of Colorado Hospital, had little doubt that Murray was right. Doctors have all seen patients who sought healing and recovery when neither was possible, often with great emotional, physical and economic costs. Doctors vow not to let it happen to them.<\/p>\n

But something bothered Fischer and Matlock about the Murray essay, and about other references to doctors dying differently: They were all anecdotal, based around \u201ca hypothesis, and not a truth,\u201d Matlock said.<\/p>\n

\u201cAnd it was being billed as a truth,\u201d he added.<\/p>\n

The truth<\/strong><\/p>\n

Nearly a half decade later, Matlock, Fischer and colleagues had collected and analyzed data on 9,914 deceased physicians and 191,426 dead non-physicians from across the country to get to the truth. They concluded that doctors don\u2019t die differently at all. Those they studied didn\u2019t spend meaningfully more time in hospice care \u2013 an admission of acquiescence to nature\u2019s imperative \u2013 and they spent about the same amount of time in hospitals and intensive care units in the last months of life as the non-physician group.<\/p>\n

Their findings were published in May, in the Journal of the American Geriatrics Society<\/em>, under the title \u201cHow U.S. Doctors Die: A Cohort Study of Healthcare Use at the End of Life.\u201d<\/p>\n

\u201cIt\u2019s a paradigm shift of what we \u2018know,\u2019\u201d Fischer said.<\/p>\n

The study took a long time, in no small part because Fischer and Matlock, in addition to their clinical work on the floors of UCH, had to figure out how to find data on deceased doctors. They tried Kaiser Permanente; they tried the Group Health Cooperative; they tried the Health and Retirement Study. None had more than a few dozen records, far too few for statistical significance. The breakthrough came with the American Medical Association, which has a master file of its physician members, \u201cso they can mail us ads,\u201d as Matlock put it. To avoid mailing ads to the families of deceased physicians, they also have a \u201cdead docs file.\u201d<\/p>\n

Matlock and Fisher used National Institutes of Health career development grant money to buy that data set, which they paid another company to reconcile with Medicare billing records in a way that would decouple names from treatments from 2008-2010. They chose the non-physicians randomly from the Medicare Enrollment Database. The huge sample sizes enabled a high degree of statistical accuracy.<\/p>\n

The findings surprised them, Fischer said. They expected that doctors would die in hospice 50 to 60 percent of the time as opposed to 40 percent of the time for the general population; that they would stay in hospice a week or two longer, having recognized the futility of further care; and that they would much spend less time in hospitals and ICUs. None of it turned out to be the case.<\/p>\n

High stakes<\/strong><\/p>\n

This is more than just another interesting, counterintuitive finding. Patients who end up dying within six months of their diagnosis consume about a quarter of all health care dollars. About a quarter of them \u2013 us \u2013 will land in an ICU during their last month of life. About a quarter of them will die in the hospital. In addition to being expensive, Matlock said, this sort of hospital care is harder on patients and families, and not just physically. Studies have found that families of patients who died in ICUs have more grief and more post-traumatic stress disorder.<\/p>\n

There are far-reaching implications, Fischer and Matlock added. Our health care system is \u201cdriven by utilization,\u201d as Fischer put it \u2013 meaning that the default is toward more care rather than less. In addition, said Matlock, advanced medical technologies enable us to delay the final reckoning in ways once unimaginable. With such tools at hand, death has gone from inevitable tragedy to being viewed as a medical failure.<\/p>\n

\u201cWhen someone dies, there\u2019s an M&M [morbidity and mortality] conference to find out what went wrong,\u201d Matlock said.<\/p>\n

Knowledge not enough<\/strong><\/p>\n

In such an environment, the assumption is that physician-patients and their families \u2013 the ultimate decision-makers in these cases \u2013 will opt for less care rather than more. After all, Fischer said, \u201cIf you talk to a room full of people, very few will say, \u2018I\u2019d like to be in the ICU, hooked to as many machines as possible, with my family in the next room talking about me in the third person.\u201d<\/p>\n

But even doctors and their families don\u2019t seem to be avoiding that. And if doctors can\u2019t, how can those of us with far less experience with the pros and cons of end-of-life care?<\/p>\n

\u201cSo much of the conversation is, \u2018If people just knew more, if they could just see what this looks like at the end of life, they wouldn\u2019t want it,\u201d Fischer said.<\/p>\n

Yet their research found that doctors did<\/em> want it, at least amid our current medical system and culture.<\/p>\n

\u201cThe bull looks different when you\u2019re in the ring,\u201d Matlock said.<\/p>\n

Their findings provide hard evidence that change has to happen at the broader health system level.<\/p>\n

\u201cI am very much into this world of empowering patients,\u201d Matlock said. \u201cBut I think if we really want to change these things, it\u2019s got to be system and culture.\u201d<\/p>\n

He\u2019s talking about a world where patients, families and health care providers base decisions on sober assessments of the benefits of such things as chemotherapy for stage 4 cancer or resuscitating patients who will soon fail regardless.<\/p>\n

Honesty, early<\/strong><\/p>\n

Matlock and Fischer admit their study is not perfect. The doctors were overwhelmingly (95 percent) male, reason enough for one journal to pass on the article, they said. But that simply reflected the reality that doctors educated in the male-dominant 1950s were passing on a half century later. Physicians did use slightly more hospice care \u2013 about two days on average. While statistically significant, Fischer said, that\u2019s not clinically meaningful \u2013 an important difference.<\/p>\n

Their paper has gotten some attention<\/a>, but it has yet to go viral like the Murray essay that inspired it. Perhaps it\u2019s a reflection of a world in which alluring opinion drowns out stubborn fact.<\/p>\n

Matlock and Fischer continue to try and get the word out, not only about their findings, but also about what they see as the foundational changes needed for more humane, rational end-of-life care. It depends on discussing palliative care with patients early in the trajectory of illness, Fisher said, \u201cwhere you continually evaluate the value of care and continually work with families and patients to make sure their goals are being met.\u201d<\/p>\n

Will she and Matlock approach the end of their own lives differently now?<\/p>\n

\u201cWe\u2019ve had a lot of conversations about, \u2018I would take this, but not this,\u201d Matlock said.<\/p>\n

\u201cBut we\u2019re all human,\u201d Fisher added. \u201cDoctors are human, and we all get scared of dying.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

The main idea of California family medicine physician Ken Murray\u2019s November 2011 essay, \u201cHow Doctors Die\u201d is simple: \u201cOf course, doctors don\u2019t want to die; they want to live. But they know enough about modern medicine to know its limits,\u201d Murray wrote. Docs recognize when enough is enough, so they choose to die at home […]<\/p>\n","protected":false},"author":23,"featured_media":2848,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[1270,262,154,1269],"class_list":["post-4731","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-daniel-matlock","tag-national-institute-of-health","tag-palliative-care","tag-stacy-fischer"],"acf":[],"yoast_head":"\nThis Hospital Life: Doc deaths reflect need for big change - UCHealth Today<\/title>\n<meta name=\"description\" content=\"The main idea of California family medicine physician Ken Murray\u2019s November 2011 essay, \u201cHow Doctors Die\u201d is simple: \u201cOf course, doctors don\u2019t want to die; they want to live. 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