By Richard P. Holm M.D.
Before my junior year in high school, I returned from a Boy Scout canoeing trip to discover my sister had been killed in a car crash. I will never forget the sadness of the moment when I walked into the house, which was filled with what seemed like half the caring and wonderful town of DeSmet, to find my Mom and Dad there grieving. It was near the end of that summer, but the beginning of a long period of mourning for my family and me.
There were lessons that came to me after my sister’s death. I realized how important support from a community could be. Consolation came from our friends, neighbors, church community, as well as people who we barely knew. It seemed more about their presence, and not their words. I noticed there were people who had trouble themselves dealing with such loss, and they sort of disappeared.
Also I realized that a funeral is not exactly a time of closure for a family, but really just the beginning of a time to accept reality and forge ahead with the difficult changes that life can and does deal out. It took me years to think about my sister and relish in her memory rather than cringe from the pain of the loss. In that sense, I know I will never have closure and that’s good.
Some 14 years after her death, while I was on the faculty of a medical school in Georgia, I found myself having to advise medical students how to talk to patients or family about sad news. I reviewed the medical literature on the subject at the time, and concluded that there is no right way to do it except to be 100% honest, and to say whatever is needed with compassion. Through the years those guidelines have sustained me while I have had the burden of sharing awful news.
Bottom line, it is being there, more than words, that consoles. Never worry about what to say, just show up, be honest, and care.
Showing posts with label death. Show all posts
Showing posts with label death. Show all posts
Thursday, March 24, 2011
Wednesday, May 19, 2010
When Grandma Wants to Pull the Plug
By Richard P. Holm MD
“We will all be dead one day, we should not pretend that it won’t happen, and we should all prepare for the experience rather than ignore it.” Recently I was asked to give a talk about the value of the Living Will, and I remember that it became very quiet after those words.
I spoke to a room full of mostly retired people, some of them quite elderly, and I explained that, too often, I have watched helplessly while desperate, fruitless, excessive, and painful health care was provided to a person certainly dying. Put it down as one more paradox in medicine. The fear of death and not facing the reality of dying can be responsible for much of the suffering that can occur at the end of life.
A Living Will, also called an Advanced Directive, is simply a tool to communicate about how you would like to die. It is not about a legal document, it is all about talking to your family. We know there is a time to intervene with fancy medical care and there is a time to let go. My final talking point: the Living Will makes it easier for families to allow a natural and comfortable death when the time is right.
After the presentation one guy told me his wife purposefully avoided coming because she didn’t want to think about such gloomy things. He said wryly, “We are all going to die. Why shouldn’t we talk about it?”
Another asked, “I still don’t know the definition of a Living Will. Does it have anything to do with death squads pulling the plug on Grandma?” I responded, “No, just the opposite. It is all about Grandma telling us when not to put tubes in, so no one has to pull a plug.”
I can’t say it was my happiest audience, and I’m afraid I may have offended some of them by being so blunt. But in this age of external chest massage, shocking paddles, breathing machines, feeding tubes, and the potential for years of vegetative bedridden life, there is hardly a more important message.
“We will all be dead one day, we should not pretend that it won’t happen, and we should all prepare for the experience rather than ignore it.” Recently I was asked to give a talk about the value of the Living Will, and I remember that it became very quiet after those words.
I spoke to a room full of mostly retired people, some of them quite elderly, and I explained that, too often, I have watched helplessly while desperate, fruitless, excessive, and painful health care was provided to a person certainly dying. Put it down as one more paradox in medicine. The fear of death and not facing the reality of dying can be responsible for much of the suffering that can occur at the end of life.
A Living Will, also called an Advanced Directive, is simply a tool to communicate about how you would like to die. It is not about a legal document, it is all about talking to your family. We know there is a time to intervene with fancy medical care and there is a time to let go. My final talking point: the Living Will makes it easier for families to allow a natural and comfortable death when the time is right.
After the presentation one guy told me his wife purposefully avoided coming because she didn’t want to think about such gloomy things. He said wryly, “We are all going to die. Why shouldn’t we talk about it?”
Another asked, “I still don’t know the definition of a Living Will. Does it have anything to do with death squads pulling the plug on Grandma?” I responded, “No, just the opposite. It is all about Grandma telling us when not to put tubes in, so no one has to pull a plug.”
I can’t say it was my happiest audience, and I’m afraid I may have offended some of them by being so blunt. But in this age of external chest massage, shocking paddles, breathing machines, feeding tubes, and the potential for years of vegetative bedridden life, there is hardly a more important message.
Friday, September 25, 2009
Surprise Death
By Shawn Vuong
In the light of the current healthcare reform debates and all of the craziness that has come with it (the infamous 'death panel'), let us not forget what this debate is truly about, the patients.
As Dr. Holm reminds us, eventually we will all come to our death. The important thing is that we must let our loved ones pass away with a little dignity and pride. To do this we must talk to our family members about their death wishes, as well as our own. This is an important and often ignored piece of medicine that never gets the attention it deserves until it is too late.
__________________________________________________________________
By Richard P. Holm MD
The late physician poet John Stone wrote of Death… I have seen come on/ slowly as rust/ sand/ or suddenly as when/ someone leaving/ a room/ finds the doorknob/ come loose in his hand.
This is not a topic about which anyone likes to talk. The poignant truth, however, is that all of us will die one day, so we should go there every once in a while. Many say they would like to die quickly and unexpectedly. Let me go at ninety, shot by a jealous lover. Or more realistically, let it happen in the night during sleep, after a joyful day, as a very old person, still with all my faculties.
As a physician, I have seen death occur in many ways. Certainly, no one wants to die slowly while suffering, or after a long period without the capacity to know what is going on. In these cases I have grown to appreciate the hospice attitude of comfort care, instead of medically trying to prolong an un-enjoyable life. Perhaps our ability to keep someone alive has gone past our ethical understanding about how to know when to allow a natural death.
But here we are talking sudden death. The kind of end that is unexpected. When we lose someone and we have to say “Why?”
I have often wondered what the ghosts of those who die so abruptly must think. Is it, “That wasn’t so bad!” or “Wow, that caught me off guard!” or “I wish I could have told my family one more time that I love them.” Or “That was a better way to go than that long and drawn out suffering way!”
I have had too much opportunity watching people hear and react to words like, “We have found cancer, and your condition is terminal.” We are simply not built as human beings to handle the hopeless sound of a phrase like that.
It is better to live our lives with hope for a reasonable future, but still knowing that at any moment this could be our last. One friend told me that when it’s his time to go, “Surprise me.”
Take home message:
1. Talk to your family about your own death wishes;
2. Finish your business and say what you should say everyday.
In the light of the current healthcare reform debates and all of the craziness that has come with it (the infamous 'death panel'), let us not forget what this debate is truly about, the patients.
As Dr. Holm reminds us, eventually we will all come to our death. The important thing is that we must let our loved ones pass away with a little dignity and pride. To do this we must talk to our family members about their death wishes, as well as our own. This is an important and often ignored piece of medicine that never gets the attention it deserves until it is too late.
__________________________________________________________________
By Richard P. Holm MD
The late physician poet John Stone wrote of Death… I have seen come on/ slowly as rust/ sand/ or suddenly as when/ someone leaving/ a room/ finds the doorknob/ come loose in his hand.
This is not a topic about which anyone likes to talk. The poignant truth, however, is that all of us will die one day, so we should go there every once in a while. Many say they would like to die quickly and unexpectedly. Let me go at ninety, shot by a jealous lover. Or more realistically, let it happen in the night during sleep, after a joyful day, as a very old person, still with all my faculties.
As a physician, I have seen death occur in many ways. Certainly, no one wants to die slowly while suffering, or after a long period without the capacity to know what is going on. In these cases I have grown to appreciate the hospice attitude of comfort care, instead of medically trying to prolong an un-enjoyable life. Perhaps our ability to keep someone alive has gone past our ethical understanding about how to know when to allow a natural death.
But here we are talking sudden death. The kind of end that is unexpected. When we lose someone and we have to say “Why?”
I have often wondered what the ghosts of those who die so abruptly must think. Is it, “That wasn’t so bad!” or “Wow, that caught me off guard!” or “I wish I could have told my family one more time that I love them.” Or “That was a better way to go than that long and drawn out suffering way!”
I have had too much opportunity watching people hear and react to words like, “We have found cancer, and your condition is terminal.” We are simply not built as human beings to handle the hopeless sound of a phrase like that.
It is better to live our lives with hope for a reasonable future, but still knowing that at any moment this could be our last. One friend told me that when it’s his time to go, “Surprise me.”
Take home message:
1. Talk to your family about your own death wishes;
2. Finish your business and say what you should say everyday.
Thursday, April 16, 2009
Breast Cancer
By Richard P. Holm MD
I've heard it said that we should all have a close brush with death about once a year, in order to keep our priorities straight.
I spoke to a good friend the other day about her breast cancer experience, and the following story unfolded. During her routine monthly self-breast exam she found a nodule; an abnormal mammogram followed; and then she had a biopsy, which showed cancer cells.
Treatment began with a lumpectomy and then followed six weeks of radiation to the site. Finally gene testing showed how she had a very favorable prognosis and wouldn't require chemotherapy. The expression favorable prognosis is a sweet duet of words, which means that the future looks optimistic, with a very good chance that the cancer won't be back.
Now it's been three years of disease free survival and she tells me the whole experience changed her life dramatically. Considering the possibility of dying and realizing that her life will not go on forever made her live more in the present. She re-thought what was important in her life, and refocused on giving time to her family.
During this difficult time my friend sensed a rising spiritual presence accompanying her, and grew to feel that she was not alone. She told me that this experience would have been ten times harder without a faith in God.
I have observed many people walk this kind of journey through the valley of death. I am a physician, not a religious leader, but I know that people who get through this experience change how they value their family and friends. They seem to listen more, treasure the little things, and savor the tastes and flavors of each day.
Sometimes we don't know what we have until we almost lose it.
I've heard it said that we should all have a close brush with death about once a year, in order to keep our priorities straight.
I spoke to a good friend the other day about her breast cancer experience, and the following story unfolded. During her routine monthly self-breast exam she found a nodule; an abnormal mammogram followed; and then she had a biopsy, which showed cancer cells.
Treatment began with a lumpectomy and then followed six weeks of radiation to the site. Finally gene testing showed how she had a very favorable prognosis and wouldn't require chemotherapy. The expression favorable prognosis is a sweet duet of words, which means that the future looks optimistic, with a very good chance that the cancer won't be back.
Now it's been three years of disease free survival and she tells me the whole experience changed her life dramatically. Considering the possibility of dying and realizing that her life will not go on forever made her live more in the present. She re-thought what was important in her life, and refocused on giving time to her family.
During this difficult time my friend sensed a rising spiritual presence accompanying her, and grew to feel that she was not alone. She told me that this experience would have been ten times harder without a faith in God.
I have observed many people walk this kind of journey through the valley of death. I am a physician, not a religious leader, but I know that people who get through this experience change how they value their family and friends. They seem to listen more, treasure the little things, and savor the tastes and flavors of each day.
Sometimes we don't know what we have until we almost lose it.
Tuesday, November 11, 2008
Tough Questions About Death & Dying
By Shawn Vuong
- When is a patient too old or too sick to receive expensive procedures?
- How can we pay for expensive healthcare for so many people?
- If we take away the "easier death" of an abnormal heart rhythm, how will people die?
These are extremely difficult questions, that I do not think many people are ready to discuss. But these are important topics for families, and are a hot topic in medicine.
One factoid that has been cruising around the medical blogosphere for quite sometime now, is that 5% of our population spends approximately 50% of our healthcare dollars. How can this be? Some believe it is all of the expensive treatment we utilize at the end of life. This time is a very difficult for the family, they may want everything done for their loved ones, when its obvious to the clinical team that there is just not much more anyone can do. But more often then not, the clinical picture is in a "gray area." How does a doctor decide that the act of performing surgery or giving the treatment may be worse for the patient than the benefits gained? The Happy Hosptalist sums up the cost effectiveness of this problem quite nicely.
How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:As a patient and a family member, you may be thinking "Why do these costs even matter? We want everything done for me (or my family member) because that's the right thing to do." Researchers at Dartmouth argue that more interventions and aggressive treatment do not necessarily prolong patient's lives, and by doing less you may be "sparing patients the agony of unnecessary tests and reducing the risk of hospital borne infections."
Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site [sic] of the big picture and do things to patients because they can. Because they lose sight of the big picture. And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.
The end-of-life decisions are not decisions for cost-effectiveness, insurance companies, or even doctors to make. The patient and their family ultimately have to decide what is the best route for them. But I hope families realize, they can let their loved ones pass away with peace and dignity without demanding every possible intervention.
Sunday, November 9, 2008
When Should the Heart Stop Beating?
By Richard P. Holm MD
In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.
Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast.
He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.
It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven.
The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.
The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.
Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?
In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.
Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast.
He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.
It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven.
The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.
The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.
Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?
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