Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

*Photo courtesy of patrick.ward04.

Source-http://www.zocalopublicsquare.org

“This isn’t good bye, it’s just see u later. God saw ur suffering n decided u should suffer no more.”

The woman with the cancer was dead. She was 45.

The news snapped the holiday cheer out of me. I realized that I, like so many, get so caught up in the torrent of dinners and parties and sales and gifts this time of year that I sometimes forget how truly ephemeral and precious life is, that life itself is the gift.

And I forget how truly blessed I have been by whatever gods there may be. It doesn’t mean that there haven’t been troubles and trials. There have. But I have had it in me to overcome. And for the mere fact of having enough and to all the people in my life who have informed my character and given me courage, I need to give a measure of thanks. So, here goes:

I’m thankful for the basic things, like food and shelter and warmth when it is cold and medicine when I am sick. I grew up staring poverty squarely in the face, but I fear that far too many have no familiarity — or even empathy — with what it means to be poor in this country, or in any country.

Poverty is a diabolical predicament that not only makes scarce one’s physical comforts, but drains away one’s spiritual strength. It damages hopes and dreams, and having deficits among those things is when the soul begins to die.

I am thankful for a loving mother who hasn’t always gotten things right, but who taught me how to grow in grace and learn from getting things wrong. She taught me what it means to live selflessly and without pride, and to find joy in giving joy.

I’m thankful for the folks at whose knees I spent my preschool days being imbued with wisdom long before I knew what wisdom was — gnarled hands moving gracefully through the air the way a fish’s fins move through water, gently touching my shoulder or grabbing my hands and steering me clear of danger.

I’m thankful for the teachers who saw me when I felt invisible, who reached through my sorrow and my sadness and, in that darkness, lit a fire in me. These are teachers who to this day encourage me like family more than faculty.

They are teachers like Mrs. Dawson, who calls me after every one of my television appearances, and says, “Hello baby, this is your grandma.” She continues with some version of: “We saw you. We were looking right at you. Everyone in town is proud of you. We love you.”

They are teachers like Mrs. Thomas — now down in health, but still up in spirit — whom I called last month. She remembered my first weeks in her fourth grade class after I’d changed schools: “You hardly let go of my skirt hem.” I didn’t recall that, and I asked her how she could. She responded without skipping a beat, “Charles, you never forget your babies.”

I’m thankful for these teachers who refuse to release me, who continue to inculcate me with love and encouragement, teachers whom I will spend the whole of my life attempting to honor.

I’m thankful for my three beautiful children who amaze me daily with their development into smart, honest, loving people, and who remain my reason for rising when I ache and pushing forward when I would otherwise stop.

I’m thankful for great friends and the love of family, the deepest bonds of earthly connection, who provide the greatest defense when the storms of life rage and the walls of the self are buffeted.

I’m thankful for the spirit and resilience and fortitude of this country’s unbreakable slaves of the not-too-distant past, whose blood courses through my veins, whose dreams I live, whose lives I honor.

I am thankful that my work is my passion, and that what I do for pay I would probably do for free.

And, I am thankful for all of you, the regular readers of my columns — and the new ones as well — who affirm me, and challenge me, and chastise me. In the end, you make my voice clearer and my resolve stronger.

Thank you all.

Source-http://www.nytimes.com

An Environment Ministry panel has denied permission to state governments to build new roads and widen existing ones in Wildlife Sanctuaries and other Protected Areas, where animals continue to die in road accidents.

The report of the panel, noting roads have “detrimental ecological effects on both terrestrial and aquatic natural ecosystems”, emphasised that roads and highways should bypass National Parks and Wildlife Sanctuaries.

Instituted in June by the Jayanthi Natarajan-led Ministry of Environment & Forests to frame a comprehensive guideline for construction/ repair or roads passing through PAs and design the best practices for such roads for wildlife conservation, the sub-committee of the National Board of Wild Life (NBWL) has recommended guidelines like avoiding new roads in National Parks and core Tiger Habitats and maintaining and repairing existing roads without widening them.

The same rules apply to Sanctuaries and Reserves but culverts, and resurfacing of damaged road sections with stone chips, can be considered for approval, the report states.

Method of such road construction, such as blasting, borrow-pit digging and their impact on wildlife should be a criteria for consideration. The same guidelines apply to roads within 1 km of National Parks/ Core Critical Tiger Reserves/ Wildlife Sanctuary, the report says.

The Committee said the Wildlife Institute of India should formulate detailed guidelines for roads through these areas.

The Committee has sought views of the state governments.

The report suggests ban on night traffic to save animals from disturbance, regulations on timing and volume of traffic, no stoppage, adherence to speed limits and setting up speed-breakers, no honking and no littering in PAs.

Measures like retaining natural animal tracks across roads, underpasses and other structures and no road construction/ repair between 6 pm and 8 am were also recommended so that the animals are not disturbed.

Standing Committee members called for a blanket rule to have only two-lane roads in PAs and their vicinity.

Source-http://www.indianexpress.com

Traffic woes Committee set up by Bombay HC makes 51 recommendations to address issue.

Even as traffic management in Mumbai remains an uphill task, a high-powered committee set up by the Bombay High Court in May last year has recommended introduction of congestion charges to restrict vehicles in central business districts (CBDs), besides pay-and-park policy for old and congested areas as well as night-time on-street parking in residential areas. The 11-member committee was formed to suggest remedial steps to ensure smooth vehicular and pedestrian movement and devise workable solutions to address traffic problems.

Creating a taskforce to select modern technology for traffic offences, integration of multi-modal transport networks, integrated ticketing system, refresher training for drivers, capacity building in Regional Transport Office (RTO) for driving tests, use of modern technology for driving test, policy to restrict registration of vehicles, station area improvement, signalisation of all junctions, intelligent transportation system, making space under flyovers free of encroachments and illegal parking, and creating inter-state bus terminals are part of a comprehensive action plan mooted by the committee. In all, the panel has made 51 suggestions.

Panel suggests congestion charges at business districts.

The committee was constituted following a PIL by the Bombay Bar Association seeking strict adherence of traffic norms in the city. On Wednesday, Chief Justice Mohit Shah and Justice Anoop Mohta, however, sought the implementation of two points mentioned in the 48-page report — sharing data and information of registered vehicles and using world-class street furniture for road marking and signages.

The report states that the data of non-transport vehicles and driving licences issued post-2006 have been digitised and shared with the traffic police. However, the action plan suggests that the transport department must take steps to scan the pre-2006 data as well.

The action plan also states that the BMC has undertaken a project for providing street furniture of international standards and made the necessary budgetary provisions. The BMC has undertaken the painting of zebra crossings. The corporation is in consultation with IIT and UDCT for improvement in methods and material used for signages that tend to fade owing to climatic conditions and traffic density in Mumbai. The court has sought compliance of the two suggestions by April 25.

“Restricting the number of vehicles in Mumbai along with congestion could be a possible solution for reducing vehicle density on roads. A sizeable amount of cess on consumption of petrol and diesel for cars in the MMR or Mumbai city, and using the proceeds for improvement and strengthening of public transport system like BEST will be considered. The issue of imposition of cess on petrol and diesel for cars may be taken up by the finance department and further implemented by the sales tax department,” says the report. The committee also suggested congestion pricing in selected areas. “The implementation of policy for congestion pricing will need the database of vehicles registered at RTOs/manpower for enforcement, etc,” it adds.

It moots establishment of a comprehensive parking unit for the city to look at on-road/off-road and vertical parking management, personnel management for operations, among others. “MCGM has invited expression of interest for implementing ‘web based paring’ for on-street parking, which involves electronic handheld devices capable of issuing of e-challans of parking fees, taking photographs of vehicles, noting vehicles’ registration numbers and transferring and storing data on a central server of MCGM. These devices will also have extendibility to use smart cards in future,” says the report.

The findings say that restricting registrations of new vehicles in Mumbai can be considered along with legal provisions as there is no law to stop the registration of vehicles in any office of the registering authority. “Transport commissioner to send a proposal to the Maharashtra government to revisit permit condition for transport vehicles for phasing out of old vehicles. Transport commissioner to also send a proposal to the government for policy initiatives to restrict registrations of new vehicles in Mumbai,” it says.

The report states that while the provisions of Motor Vehicles Act do not provide for “vicarious liability”, in order to adopt technology-based enforcement, the vehicle owner will have to be held equally responsible for certain offences by drivers.

Suggested Measures

Provision of vicarious liability of owners in case of offences committed by drivers.

Introducing congestion charges to restrict vehicles in central business district.

Congestion pricing in selected areas of the city.

Infrastructural facilities like test tracks to improve quality of driving tests.

Capacity building of regional Transport Office for driving tests.

Restricting registration of new vehicles to be considered along with legal provisions.

Taskforce to select modern technology for traffic related offences.

E-challan system with integrated e-payment options and alerting the offenders.

Appoint consultants to prepare parking policy for Greater Mumbai in consultation with traffic police department.

Creating a comprehensive parking unit.

Capacity building in urban local bodies and enforcing agencies.

Source-http://www.indianexpress.com

 Following the footsteps of bigger metropolitan cities like London, Milan and Tokyo, Beijing is set to implement the car congestion fee in order to cut down on air pollution by 2017.

Car emissions are believed to be the root cause for one-third of air pollutants in the city and also lead to a lot of congestion in certain areas and with this move, the Chinese capital hopes to limit car use in the center of the city.

According to China Daily, the congestion charge would be levied mainly on vehicles in the downtown area and will be set out in the near future by the Beijing Environmental Protection Bureau and Beijing Commission of Transport.

Spokesman for the bureau, Fang Li said that whoever pollutes the air is responsible to clean it up and next year the capital will also see ban on private cars at certain times and areas.

Air pollution incharge at the bureau Yu Jianhua said that the government will hold public hearings before the implementation of the congestion fee and regional vehicle restriction, and will widely gauge public opinion.

Residents are reluctant for such a fee as they believe that the restriction on private vehicles would be inconvenient and suggest government cars take the lead and compensation be given to car users.

Under the new restriction, to be carried out in 2014, vehicles from outside Beijing will be forbidden from entering the Sixth Ring Road unless with permission, the report added.

Source-http://www.business-standard.com/

“Mobility in medium and big cities is a huge challenge due to congestion during peak hours, which is mainly due to excessive use of private vehicles. There is a need to resolve the congestion issues urgently for improving mobility of people,” secretary of the Union ministry of urban development, Sudhir Krishna, stated in a letter addressed to all chief secretaries.

‘Excessive use of private vehicles’ on limited road space available is inefficient use of precious urban land. There is a need to discourage the use of private vehicles in select core areas of the city to increase the mobility of people at large, so that they can reach their workplaces, business centres and shops in time, without losing valuable working man hours, Krishna said in his letter. The congestion charge is premised on a basic concept – “charge a price in order to allocate a scarce resource to its most valuable use”. However, before introducing the congestion charge, the pre-condition is that there should be a good public transport system in place in the concerned city and proper facilities for pedestrians and cyclists, Krishna said.

The ministry has also cited case studies of congestion charging in central London and Singapore. “There are several cities the world over where congestion charges in one form or the other area being charged from private vehicles for many years. It is desirable to study the congestion pricing system in these cities in detail, and devise our own method. The results of congestion pricing in foreign cities have been impressive. Traffic in central London went down by about 21% and traffic speeds went up by about 10%,” Krishna wrote.

Municipal commissioner Mahesh Pathak wasn’t convinced with the road congestion tax suggestion for Pune. “It would be very difficult to implement. There are multiple entry or exit points. Moreover, there is no city in the country where such a tax is being collected,” said Pathak.

Senior traffic officials say such a tax should be ideally implemented, since it will help reduce traffic congestion. However, it is for the municipal corporation to decide on levying such a tax, the traffic officials said.

PMC and traffic police proposals on congestion tax

** In August 2007, the then municipal commissioner Pravinsinh Pardeshi had floated the idea of levying a new vehicle tax to arrest the growth of vehicular traffic. The proposed tax was proposed in addition to the registration charges and taxes paid to the Regional Transport Office, and if implemented, it would have been calculated based on the number of vehicles owned by a family. “We need to discourage the number of personal vehicles in the city, which are growing at an alarming speed,” he had said. The proposal did not work out, with staunch political opposition.

** The Pune traffic police in November 2009 sent a proposal to levy congestion charges on some of the busy city roads passing through the central peth areas of the city for reducing traffic. Besides proposing congestion charges, the traffic police had also stressed on the need to ban four-wheelers and two-wheelers on some busy roads, and turn them into walkways for citizens. The proposal also said that heavy parking charges should be collected from vehicle owners in the congested areas

Source- http://articles.timesofindia.indiatimes.com

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