Tuesday, March 13, 2012


A colleague recently related the following story.

Two friends were flying over the Pacific Ocean when their plane crash landed at night on a remote island.  They were captured by the local natives, who took them back to their village and brought them before the chief. 

Standing in front of the fire, the chief walks to the first and says, "Death or chi-chi?"  The captive has no idea what on earth chi-chi is, but certainly it must be better than death.  He boldly chooses chi-chi.  The chief then takes out his knife and proceeds to poke out his eyes, chop off his ears, cut out his tongue, and lop off his balls - but he lives.

He then turns to the other prisoner and poses the same question, "Death, or chi-chi?"  Seeing the state of his friend, he quickly responds, "Death!" to which the chief replies, "Ok - but first a little chi-chi!"

As a doctor, I decided how much chi-chi to administer every day. 

Have you ever been a patient in or visited an intensive care unit?  If so, you've seen the chi-chi.  It's well intended chi-chi and usually necessary for survival.  Other times, however, it's futile - yet we still do it.  Take the following example of a patient that I'm currently caring for in the ICU.

55 yo M with end-stage alcoholic cirrhosis was admitted a week ago for e. coli sepsis from peritonitis (abdominal infection common in cirrhotics).  His liver disease is as advanced as I've ever seen in a patient that is alive.  He is cachectic (weighs about 120 lbs - much of which is ascites - or fluid buildup - in his protuberant abdomen).  His arms are thin as pencils, yet his legs are the size of tree-trunks from all of the swelling.  His hemoglobin is 7, platelets of 12, INR 5.6. 

Most importantly, because of his alcohol use he is not a candidate for the only procedure that can save his life - liver transplantation.  Life expectancy for someone with this severe of liver disease is less than 3 months at most - realistically probably closer to a few weeks to a month at best.

He's brought to the ER by concerned family members because he is lethargic and having difficulty breathing.  He's in septic shock from the overwhelming infection.  Here's a brief synopsis of everything he's had done to him thus far (pictures hyperlinked).

Poked my times for IV's, blood draws
Restrained in 4 point restraints
Large central venous catheter inserted (Cordis)
Hemodyalisis catheter inserted
Femoral arterial line
Chest tube
Foley catheter
Rectal tube
Another paracentesis
NG tube

These are all done at bedside - sometimes with sedation and sometimes without.  He looked similar to this.

Remember the final scene in Braveheart when William Wallace gets tortured to death?  Some of those instruments look eerily similar!

Now take a step back and look at what we've done.  We've taken a poor patient with a terminal illness (remember - lifespan probably in weeks-months range) and subjected him to all sorts of chi-chi.  And for what?  In the best case scenario we keep him here for 1-2 weeks, he gets well enough to leave the hospital but is so weak and sick that he lives out the rest of his life in a nursing home, and then he dies.  The other possibility is that we do all of that stuff and he still dies in the hospital.  Either way, he dies.  And up to this point we've done a lot of chi-chi. 

How about the cost?  He may rack up a few hundred thousand dollars in medical costs (or more) just to be tortured before he dies.  See my first post for the cumulative economic burden this type of care imposes. 

Chi-chi isn't cheap.  Medicare spends 55 BILLION dollars on doctors and hospital bills in the last 2 months of a patients' lives.  It is estimated that 1/3 of the entire Medicare budget is spent in the last year of life.

I believe that the cultural mindset of end-of-life care in America is completely backwards.  Have you ever thought about how you would like to die?  Do you want to die in an ICU restrained, naked, and with tubes coming out of every orifice?  Or would you like to die peacefully at home in the presence of loved ones? 

If I am still relatively young, healthy, have a good quality of life and for whatever reason wind up in an ICU, I'll take the chi-chi as long as there's a reasonable chance that I get to return to my previous state of health.  But if I am 75 years old, have 5 chronic health conditions and can't walk from my couch to the toilet without getting short of breath, I'll pass on the chi-chi.  No thanks.  Not worth it.  I've seen how awful it is, and I don't want it.  I'd rather die.

Instead, when I get to the point that I have no quality of life, I'm hoping I qualify for hospice.  Studies have shown that people fear pain more than death, and I'm no exception.  Keep me comfortable, that's all I ask.  And no tubes or needles!  Keep your damn chi-chi to yourself!

Most patients find themselves on the receiving end of the chi-chi because we, as physicians, are lousy at communicating our real thoughts to patients and their families.  We assume you want aggressive care because you came to the hospital.  It's what we know how to do, and we're good at it.  Somewhere along the line we have been taught a 'life at all costs' mentality.  But sometimes, when we take a step back and look at the big picture, it's the wrong decision. 

I am very pro-hospice/palliative care because I've learned it's what many patients actually want.  When patients such as those described above come in to the hospital, I really try to have a good discussion with them about what my honest thoughts are.  Does it take more time to do this?  Yes.  Do I get paid to have these conversations (more on this in a bit)?  No.  But I feel it is part of my duty.  Sometimes they aren't receptive to this kind of frank discussion, but that rarely is the case.  Most times they are glad to finally talk openly about death.

Patients occasionally bring me gifts in appreciation for the care I have rendered.  And guess what?  The most gifts/praise/appreciation that I have been given are not from patients that I 'save,' but rather those whom I've referred to hospice.  Some of the most touching conversations have been when I've taken the time to sit down with the patient and their loved ones and ask them what they really want.  I've been surprised at how many people choose the hospice/palliative approach when given the choice.  It's like a huge weight is lifted off their shoulders.  I really think most people in that situation would choose hospice - they are just waiting for someone to bring it up.

Earlier this year I even had a terminal patient who was a retired hospice nurse (which she didn't disclose to me at first) who never even mentioned hospice until I brought it up with her and her husband!  They were so relieved to have a frank end-of-life discussion and that someone was very honest with them.  The patient's husband even sent me a hand-crafted gift as a token of appreciation.  I can recall a number of similar circumstances.  Many times by the end of the discussion we're all in tears.  Sure it's difficult, but it's necessary.

So why don't we have this conversation more often?  Recently there was a proposed amendment to Medicare that would include funding for end-of-life care discussions between Medicare recipients and their PCP's.  Physicians would be reimbursed for an outpatient visit every 5 years to address this very issue and come up with a long term plan.  This would be the ideal setting - it's important to discuss these issues before you are acutely ill and unable to speak for yourself.  Great idea, right?  All was well until Sarah Palin got word of this and criticized it as being a "death panel."  Nationwide outrage ensued, and that portion of the bill was removed. 

Thank you, Sarah Palin.  Thanks for offering your opinion on something you know nothing about.  Come spend a week with me in the hospital and let's see if you change your mind.  Once you see the chi-chi, you'll never look at healthcare the same.  Until you have been through it yourself or seen someone go through this, you will never understand.

Does this make me a part of a death panel?  I guess by definition it does.  It's funny that patients are so appreciative of my evil tactics.  Heaven forbid they should want to die in a humane, dignified manner rather than lying naked in a cold ICU bed, restrained and defecating on themselves.  If you want chi-chi, I can give you chi-chi.  But if you don't want it, I would be more than happy to send you home with what you really want - a roomful of loved ones and plenty of pain medication. 


  1. FIRST...but in all honesty this post just made me depressed. I think your "chi-chi" analogy is a bit over-the-top and sensationalistic (as there is no prospective or retrospective randomized trials that demonstrate any quantifiable or qualifiable benefit from head mutilation and castration), but I guess it sometimes takes a bit of hyperbole to get a point across.

    Similar to your second post, this example just reiterates the fact that physicians need to establish a significant amount of candid communication with their clientele to reach whatever decision the patient believes most compatible with their goals and beliefs. As we cannot deprive morbidly obese people extra bacon and cheese with their burgers, we too cannot withhold existing resources that may prolong life without quality.

    If you truly take a moment to think about it, the financial burden placed on our nation by offering both more bacon/cheese, or an oscillator, are one and the same.

    1. Thank you for the insight, jyalpha.

      You make some valid points - especially on the financial burden of bacon and cheese (for the record I love both). More on that in a future post, so stay tuned.

      I disagree, however, about offering treatments that prolong life without quality - at least in some situations. Recall that the first rule of medicine is to "do no harm." If I subject a patient to pain and suffering in order to prolong his life without quality for a few days or weeks, I feel that I have done more harm than good. Certainly there is no right or wrong in this decision as it is open to interpretation of what you consider 'harm'.

    2. Update -

      The patient that I wrote about in the above post is now in the care of hospice. After a long discussion with family, they decided that he (patient) would not want any further aggressive treatment and would rather be made comfortable. Hospice was called an within 3 hours he was at home with his family, where I presumed he peacefully passed away a short time later.

  2. http://www.kevinmd.com/blog/2012/03/full-code-default-status-patients.html?utm_medium=twitter&utm_source=twitterfeed

  3. Excellent read zm! Thanks for the link. I'm all for the DNR or, as I've recently heard, AND (Allow Natural Death) as the default that has to be opted out of. Not sure it will fly in the US for quite some time because of the public outcry that would follow, but maybe with time attitudes will change.