Wednesday, March 7, 2007

Slate on why doctors don't do death very well


Slate's Medical Examiner column has a recent post on "Why doctors are bad at mortality" by Kent Sepkowitz (a physician) (Slate articles are available for free). It's a provocative essay and worth a read. (It's is somewhat of a book review of the books Final Exam by Pauline Chen, and The Lonely Patient by Michael Stein.)

Sepkowitz's major thesis seems to be that doctors are bad at death because it's human nature and therefore it's ok to flee from the deathbed. He makes some remarkable claims:

"In fact, doctors aren't bad at handling the details of dying. We know how to ease pain, promote comfort, and arrange the medical particulars. But we are disasters when it comes to death itself, just like the rest of the human species.... I admire Chen's and Stein's pep-club optimism, but they might have integrated Ernest Becker's seminal Denial of Death into their discussions. Becker's basic point is that all of human behavior can be traced to our inability to accept our own mortality. Cowards that we are, we not only refuse to consider our own inevitable death, but our patients', too: We duck the tough discussions, flinch and flutter and order another test, and finally leave it to a (usually much younger) colleague to sit down with the family. We don't slink away because we are bad people; we slink away because we are people."

I choked on my bagel when I read the first two sentences which seem patently false, based on decades of good documentation of bad pain & comfort mangement at the end of life in the US. That aside, he uses this premise to make this closing argument:

"I agree with Nuland that doctors' failure to deal well with their patients' deaths is not a bad habit that can be corrected by medical-school remediation. Doctors and patients would be better served if we stopped sophomorically pursuing the "good death" reassuringly reducing the end of life to another commodity subject to adjustment and negotiation. Instead, we should do what we can to make the dying and those who survive a tiny bit more comfortable when the time comes."

I've blogged before about my disdain for the (at least rhetorical) consumerization of dying and death ("It's all about choice!") that accompanies some discussions of dying & palliative care, but he is using this to claim essentially 1) physician behavior around death is somehow inate, not learned, and therefore not subject to improvement/education ("medical-school remediation"), and 2) we can't really do anything to ease the suffering and dislocation of death anyway (other than make people a tiny more comfortable which apparently is super-easy for most doctors). This seems to be shaky ground on which to excuse what is essentially physician abandonment of the dying (which he describes in the first quote). Death, pretty much by definition, sucks--full of anguish in even the best of circumstances--for patients, families, and frequently clinicians. To pretend otherwise is naive (& I doubt that is what Chen & Stein claim), but to pretend that we can't train future generations of physicians to care for dying patients and families in better and better ways just because we can't fix the existential finality of death is dead wrong and a little weird. Anyway, I guess I'll throw those books onto the "to read" pile.

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