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I Don't Believe You

It's amazing how disrespected we can be in our field; especially by other physicians outside of the specialty, when they are dealing with their loved one's demise. In no other field of medicine does a clinician have to go through so much convincing of what is being seen and how to manage it. In spite of our expertise, we are questioned and re-questioned and outright disbelieved in what we are saying. As I said, shockingly some of the worse offenders are other physicians, who have no clue about mortality and its nuances, but full of ego, "step in" to take charge. It's akin to a dermatologist stepping into the cath lab and expecting to run the show.

The management of mortality is a specialty field. It is not pseudoscience or made up. It is not based on whim or lacking evidence - although we do need more studies (yes, studies) of death. Recognizing and managing dying well is an acquired skill which requires years of expertise and a critical understanding of an area which is misunderstood by the masses and most of the medical field. Accurate prognostication and management of dying requires intimately knowing what different trajectories of decline look like. The management requires many modalities and dynamic dosing of varied medications to keep patients comfortable until the end.

It's clear where all this refutation is coming from - and it's why we try to be patient with the disbelievers, as fractious as they get. It's that the disbelievers are so steeped in the disbelief of death that they disbelieve anyone affiliated with death. We, whose "business" it is to deal daily with dying, are considered part of an entity which can't be real. Only aggressive, life-prolonging care is real medicine; dying is a construct which only exists if you fail at prolonging life. If you're dealing with death, then you are failing at prolonging life; you need to step aside and let the life-prolongers show you how it's done.

But the problem with this conceit comes down to the patient. When disbelievers dispute that dying is occurring, they then dispute what it takes to manage the patient along that trajectory. They aim for the wrong goal, prolonging life at all costs, rather than a quality of decline. I have seen patients pass in anguish from all permutations of dying because the family staunchly refuses to follow the recommendations of the hospice - they will follow the inventive recommendations of the cardiologist MD uncle, or the holistic practitioner cousin, but the hospice, preaching a peaceful, properly-medicated end of life, is crazy. It is hard to fathom that disbelievers would allow their loved one to suffer so much, simply because they cannot come to terms with what is going on, but they don't see what we are seeing and this has direct consequences on the patient.

It's not easy to engage with disbelievers. But again, we need to have compassion for them. They simply do not know what we know through years of education and experience. The most we can continue to do, as I try to do here with this blog, is educate, educate, educate. And gradually, one by one, each disbeliever of death will hopefully see the truth of what we are preaching: there's an art to managing the end.


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