Tuesday, November 23, 2010

Facing Death

The PBS Frontline Documentary, Facing Death aired tonight at 9pm. Here you can watch it online. Sunday night, a group of folks interested in palliative care viewed it online and simultaneously held a 'tweetchat' in which we commented on the documentary and asked questions of one another. Here is a write up of that event. I am glad that PBS Frontline did this documentary. Here are a few thoughts:
  • The patients, family members and medical staff at Mt. Sinai allowed incredible access into very personal matters and did so in ways that made them vulnerable. I am appreciative that they allowed this window into this part of our health care system and death in an ICU. Each of the people shown in the show is someone's mother, father, husband, wife, child....and I want to say thank you for allowing this show to be filmed.
  • I hope PBS Frontline will follow up later with a show that focuses on palliative care, which is care that focuses on maximizing quality of life, regardless of disease state or prognosis. The documentary just shown provides a vivid look at the process of dying in an Intensive Care Unit, but does not realistically or effectively chart out other care choices that are available to patients (non-hospice palliative care and hospice, for example). In that sense, the show doesn't provide a full account.
  • There is a continuous use of the phrase 'do nothing' in the documentary. It paints the only choice as 'doing everything for a cure, no matter how remote and no matter the side effects' v. doing nothing. This language paints a false dichotomy. Palliative care and hospice are something. Non-hospice palliative care can be received while patients receive chemotherapy or other treatments designed to cure illness. Hospice is a comprehensive team based approach to providing palliative care to persons who are believed to be very near death. Both non-hospice palliative care and hospice are something, and are available in Medicare, Medicaid and private health insurance. The do-nothing language is a disservice and is incorrect. Again, the best way to remedy this is a follow up show that charts out the other choices.
  • I wanted to hear more from the nurses. My wife is a Peds HemeOnc nurse and I generally find nurses to be quite straightforward and I think ahead of the curve (ahead of docs, families) in realizing when a given treatment plan may no longer make sense. They may just be the most honest. I don't think they have as much ego tied up in the death of a patient as do physicians.
  • There is a skewed nature of the deaths this show chronicles. A little over 8 in 10 deaths in the USA occur among persons who are age 65 and older (they represent around 13.5% of the population). These patients are typically covered by Medicare, the government single payer health insurance system for the elderly. Only 1 of the 5 or 6 patients shown in the documentary are age 65 or older. I am not sure what that means, or why this was done, but simply point this out as a fact.
  • This show is a small part of improving our ability as a nation and a people to talk about hard things related to death and dying. All of us will die, it is only a matter of when and from what. And what options and choices we will have. The absurdity of the death panel nonsense during health reform shows how far we have to go to learn how to have an honest discussion about the limits to what medicine can do. This show and more like it are a step in the correct direction.


  1. When I was a corpsman working for nurses, I always thought that we were ahead of the curve, ahead of our nurses. Meh. The issue is one of responsibility. When you are a doc, you have the final responsibility and tend to err on the side of doing too much since you really dont want someone to die unnecessarily. It's hard to do. However, good docs do listen to their nurses. They often see things we miss. Dos also worry more about the legal consequences of decisions.


  2. I agree good Docs listen to nurses. That is what my wife says. They all best function as a part of a team, but the docs do have a special role in the medical team. So do the nurses. We need to make sure the patient and family do as well. One of my overriding thoughts of watching the episode is what does informed consent actually mean? Have patients really heard the probability of success? How is success defined?