Monday, April 16, 2012

ER Doc's Book: "It's OK to Die"

It’s probably not a great marketing strategy to devote a book to a subject nobody wants to talk or hear about. But maybe the importance of the story might transcend the reluctance to engage. I hope that’s the case with “It’s OK to Die.”
Alabama Emergency Physician Monica Williams-Murphy and her husband and co-author, Kristian Murphy, clearly believe in the importance of their subject, and I’m impressed with their dedication and their vision. It deserves to find an audience with physicians and the general public alike. 
“From a strictly scientific-materialist perspective, we are the first generation of any species to keep our weakest, oldest, and actively-dying members alive by artificial means for extended periods of time,” Dr. Murphy writes. “It is estimated that 25 billion dollars a year is spent on people who ‘live’ on ventilators.”

When a person can no longer speak or comprehend, loved ones face decisions they’re hard-pressed to understand, let alone make wisely and compassionately. A dying patient’s best interests regularly fall victim to the quandary. “It’s OK to Die” is a user’s guide to end-of-life decision-making, told compellingly and accessibly while underscoring the importance for families of not putting off these conversations. “It’s OK to Die” shares real scenarios as it walks readers toward making smart choices for themselves, and putting those choices in writing. 
“We have reached an historical era in which most modern American have become strangers to death,” the authors write. “Except for the elderly themselves, the rest of us are one or two generations removed from experiencing death as part of life.”
Even someone as clear and purposeful as Dr. Murphy waited nearly too long. She didn’t have the conversation with her own beloved grandmother until the latter was in the process of dying. The conversation between the two of them, and with Dr. Murphy and her extended family, is moving and revealing of the importance of such a dialogue to both the living and the dying.
Dr. Murphy and her husband also write of making choices without knowing their loved one’s wishes -- and living with the regrets of decisions made in fear.
“Loving someone does not obligate you to use every medical intervention available to prolong his life,” Dr. Murphy writes. “In fact, deeply caring for someone can mean that you should help to make him comfortable -- and let him go.”
“It’s OK to Die” is a straightforward look at the normal dying process. It is for doctors who struggle to tell the patient, You’re dying, and for patients and families who don’t want to hear it. 
As an Emergency physician -- not a palliative care or hospice doctor -- Dr. Murphy offers a unique insight into end-of-life care. Emergency physicians invariably are tasked with making urgent decisions with very little information -- and quite possibly no history whatsoever with a patient. In such circumstances, regrettable decisions are made -- seldom with the result of a “good death.”
“So, let me ask you,” Dr. Murphy writes. “Why would a 90-year-old woman with bedsores, who cannot feed herself, who can’t walk, and is chronically confused, be transferred to my emergency department for me to save her life, if she should suddenly become even more ill? For the record, this happens all the time.”
Kristian Murphy and his wife are children, grandchildren, and parents. In their own lives, they’ve experienced good and bad decision-making at end of life. Their insights are personal, and their recommendations hold promise for our dysfunctional healthcare system.
Dr. Murphy is a strong proponent of good palliative care, advance directives (especially the systemically accessible POLST or, in Massachusetts, MOLST forms), and the Personal Self-Assessment Scale, a tool for physicians to help patients “(make) medical decisions in advance based on objective markets of quality of life.”
Quality of life is such a loaded phrase, and the meaning or perception changes greatly depending who uses it. So ideally, answering questions about quality of life are best left to the individual patient. 
And yet, patient choice can itself result in harm both to patient or the care team. So perhaps another appropriate market for this book is state politicians, especially the legislators and governors in Idaho and Oklahoma who put the force of law behind provision of bad end-of-life care.
If they’ll listen to any voice of reason, maybe it’s that of an Alabama ER doctor, who just might stand a chance of convincing people there’s not a death panel lurking behind every end-of-life conversation. (In one vignette, Dr. Murphy treats a dying man whose wife insists that “hospice kills you.”) 
The subject may be one that nobody wants to talk about, but the book is one everyone with a pulse should read, while they can.  


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