Bernard Gitler, MD, had been practicing medicine for nearly 20 years when he decided to take out a living will in 2000. A cardiologist specializing in hypertension, heart-valvedisease, and cholesterol disorders at Sound Shore Medical Center in New Rochelle, he was no stranger to mortality, but something had changed—gradually, almost imperceptibly. Again and again, he’d seen patients land in intensive care units with no advance directive for emergency treatments, their family members unable or unwilling to assume the responsibility of withdrawing support. Around that time, his father bowed to biliary cancer as gracefully as the disease would allow, and he couldn’t envision anything less for himself. “I wanted to make sure that I didn’t become one of them,” he says, referring to some of his patients. “I didn’t want a feeding tube. I didn’t want a breathing machine. I didn’t want to just exist without cognitive function.”
Dr. Gitler is not alone in his anxiety. Last spring, the Archives of Internal Medicine released a study revealing what perhaps only the most grizzled healthcare veterans could have suspected: When faced with critical health decisions, many doctors will pursue different treatments for themselves than they might for their patients. In one scenario, 1,600 primary-care physicians were asked how they’d treat a hypothetical strain of avian flu. One option caused a 10-percent fatality rate and a 30-percent hospitalization rate, while the other was an immunoglobin treatment that would cut the hospitalization number in half but cause death in one percent of users and paralysis in four percent. Sixty-three percent of doctors elected the treatment with the higher mortality rate, but only 49 percent said they’d recommend the same to their patients. Implicit in these numbers is the suggestion that doctors, having witnessed how grueling and debilitating certain life-sustaining treatments can be, will do anything to avoid them. “Physicians decisions’ [for themselves],” the authors of the study conclude, “are significantly influenced by their perspective.”
Over the past 30 years, this perspective has begun to shift; modern medicine can keep sick people alive longer, but it can’t always improve the quality of those lives. The roots of this conundrum can be traced back to the Age of Pericles. While theories abound, it’s widely accepted that the Greek physician Hippocrates penned the original doctor’s oath of ethics in the fifth century BC. Two and a half millennia later, it remains a rite of passage for all manner of healthcare professionals. In one modern version of the Hippocratic Oath, sandwiched between promises to respect the scientific discoveries of a fellow physician and to treat one’s patients with warmth and understanding, is the tenet that a doctor must avoid the “twin traps of overtreatment and therapeutic nihilism.”
“Doctors are supposed to inspire hope in their patients,” says Daniel Callahan, co-founder of the Hastings Center, a nonprofit bioethics research institute in Garrison, New York. “They’re trained to be very aggressive in keeping people alive, but it can be a slippery slope.”
The dying elephant in the room is that end-of-life care has emerged as a new kind of big business. In 2009, Medicare paid $50 billion alone in doctor and hospital bills for patients with less than two months to live. Perhaps it’s no coincidence, then, that the rising costs of end-of-life treatments have coincided with the emergence of hospice care—a form of nursing that often proves less expensive for the terminally ill. According to US News & World Report, nearly two out of every five people who died in the United States in 2008 were in a hospice program at the time of their death, and more than 1.5 million had received hospice care.
Meanwhile, the dialogue over ICU treatments has grown increasingly fraught. As machines like pacemakers and defibrillators have become more sophisticated, doctors have been forced to temper the sometimes unrealistic expectations of patients and grieving families that these devices can inspire. This can prove trying for a group that, with the possible exception of psychiatry (and even then there are those strict Freudians), has never been lauded for its communication skills. For proof, one need look no further than New York’s Palliative Care Information Act, which took effect in February of last year. Written in conjunction with Compassion & Choices of New York, an affiliate of the nationwide not-for-profit advocating greater end-of-life treatments and alternatives, it requires healthcare practitioners to provide counseling and palliative care options to patients facing a terminal illness.
“I don’t think any family practitioner who’s really involved with their patients wouldn’t do that anyway,” says Dr. Gitler. Elizabeth Phillips, MD, a medical oncologist in New Rochelle, regards the Act as “meaningless” for similar reasons and suggests, however obliquely, that it could intrude on the doctor-patient relationship. “I never want [my patients] to feel I am abandoning them,” she says, before tossing another log on the fire: that government has complicated decisions about life-sustaining treatments. “Having someone who is frightened, senile, or has a psychiatric disorder and is obviously dying decide whether they want to be resuscitated or not is cruel and inhuman. Ideally, people should be asked their wishes when they’re not immediately threatened by death, though it’s a topic none of us wish to discuss. The next best alternative is a healthcare proxy.”
But what happens when a patient in critical care hasn’t assigned a friend or family member to make these decisions?
The degradation often tethered to end-of-life treatments is not lost on the men and women who prescribe them. If doctors’ perspectives are influenced by their professional experiences, then it only follows that their views on mortality are shaped by their work both in and out of an intensive care unit. Michael Silver, MD, a cardiologist in White Plains, can recall vividly an elderly female patient who made frequent appointments to discuss what he describes as “middling complaints.” One day, she arrived at his office bearing a gift—a poem she had composed examining her fear of death. “At her stage, she felt that every illness was going to be the illness that killed her,” he recalls. “She wanted to impart that concern and sensitivity to me. “
Speaking to a host of physicians with specialties ranging from oncology to geriatric care, what emerges is a kind of pre-packaged fatalism, hermetically sealed by years of medical practice. And herein lies one of the paradoxes of modern medicine: While they are often obligated to pursue aggressive end-of-life treatments for their patients, doctors will choose the path of least resistance for themselves. Nearly all of those who agreed to be interviewed for this article admitted that, under the proper circumstances, they’d be more inclined to sign a DNR (do not resuscitate) form than the average layperson. Dr. Silver acknowledges that, when confronted with their own mortality, physicians enjoy a certain privilege of perspective. “Doctors have a more intimate knowledge of the consequences [of certain treatments],” he says. “They understand the real prognoses and what lifestyles they entail.”
Jeffrey Escher, MD, a physician at Saint Joseph’s Medical Center in Yonkers, puts things more bluntly: “I enjoy living, but I don’t want to hang around half alive and half dead for an extended period of time. Most doctors would rather be here one minute and gone the next. I’ve rarely met one who feels otherwise.”
Of course, enlightenment has its limits. Bernard Bernhardt, MD, an oncologist at Sound Shore Medical Center and a colleague of Dr. Phillips, has been practicing medicine since the Kennedy administration. To his mind, a doctor’s stoicism in the face of his own mortality amounts to little more than clinical posturing. “A guy can be Mr. Cool, and then, at the last minute, he can go crazy,’” he says. “The truth is you never really know how you’re going to go.” Ironically, this brand of stoicism may be the only vocabulary that doctors have to articulate their fear of death. Dr. Bernhardt, to wit: “When my time comes, it comes. What am I going to do?”
The bereavement meditation room at Hospice Care in Westchester & Putnam, Inc. overlooks a stretch of Interstate 287 in White Plains. The space is spare—two floral-patterned sofas atop a different floral-patterned carpet, a glass coffee table, and a smattering of artwork. A poster of van Gogh’s Starry Night hangs on the far wall. A porcelain angel spreads its wings on the radiator by the window.
According to Harold Federman, the room is seldom used. That’s because the Visiting Nurse Association of Hudson Valley, of which Hospice Care in Westchester & Putnam, Inc., is an affiliate, treats its patients in their homes. As the latter’s medical director, Federman is its high priest. A soft-spoken man with bifocals and a thinned-out tuft of white hair, he has been working in hospice care since the 1980s. To his mind, one of the central problems with modern medicine is doctors’ failure to connect with the people they’re treating. Federman can recall, with a clarity that causes him to furrow his brow, administering chemotherapy to a housebound patient and teaching her husband how to administer an injection of morphine. “It’s easy to see someone in an office for ten minutes and not realize the depth of his or her suffering,” he says. “I used to make home visits. It was a different era.”
If the medical profession offers its practitioners a unique view of mortality, then hospice care specialists, whose job it is to make a patient’s last days as comfortable as possible, operate in the narrow space separating life and death. “Many years ago, our society was more comfortable with death,” Federman says, after assuming a seat on one of the meditation room’s twin sofas. “I think doctors and clergy are the last remaining bastion of people who are acquainted with mortality, and are, therefore, more philosophical.”
When asked how he’d respond to a terminal illness, whether he’d eschew aggressive treatments for what might prove to be a more dignified end, Federman blanches. “People try to reduce this question to an either/or [scenario],” he says. “The worst thing in the world is to decide beforehand what you’re going to do, because that never works. There shouldn’t be an easy answer. Medicine should not be easy.”
Jacob Sugarman, a graduate of the Arthur L. Carter Institute of Journalism, is a freelance writer living in Brooklyn.