[RADIOLAB INTRO]

JAD ABUMRAD: Hey, I'm Jad Abumrad.

ROBERT KRULWICH: I'm Robert Krulwich.

JAD: This is Radiolab.

ROBERT: The podcast.

JAD: Oh, does that—how it usually works? Do you say 'the podcast?'

PRODUCER: Yeah.

ROBERT: [laughs] A few times.

JAD: Somehow it just sounded so different to me then.

ROBERT: So different. Yeah.

JAD: Something just got—that's really how we did it?

ROBERT: [laughs] I thought we could try that.

JAD: We could just do it differently then.

ROBERT: Let's do it differently. Should I go first?

JAD: Go first.

ROBERT: That always shocks you.

JAD: Do it.

ROBERT: Hi, I'm Robert Krulwich.

JAD: I'm Jad Abumrad.

ROBERT: And this is Radiolab.

JAD: The podcast.

ROBERT: And on this podcast, we're going to have a conversation. Not an easy conversation, I wouldn't say.

JAD: No. It begins really with a difficult question, maybe the most difficult question a person can be asked. And asking it for us is our producer Sean Cole.

SEAN COLE: Well, this story starts with a doctor.

[phone rings]

SEAN: A guy named Joseph Gallo.

SEAN: Hello, can you hear me, Joe?

JOSEPH GALLO: Yeah.

SEAN: Okay, great.

JOSEPH GALLO: Yeah.

SEAN: He's a real sweetheart, actually.

JOSEPH GALLO: I feel like a celebrity. You're sending a sound person here to record.

SEAN: Joe's an MD, but he's also a professor.

JOSEPH GALLO: At Johns Hopkins University in Baltimore.

SEAN: And he's been working on a study that I just frankly find totally fascinating.

JOSEPH GALLO: Yeah, let me—if I ramble just stop me.

SEAN: So here's the story. A long time ago ...

JOSEPH GALLO: In the 1940s and early '50s.

SEAN: ... Johns Hopkins launched something called the Precursor Study, and all of these graduating medical students ...

JOSEPH GALLO: 1337 students.

SEAN: ... signed up.

JOSEPH GALLO: Between 1948 and 1964.

SEAN: And every one of them agreed to be poked, prodded, examined up and down.

JOSEPH GALLO: You know, their blood pressure, their weight.

SEAN: Asked all these questions.

JOSEPH GALLO: Their habits. How much exercise they took. They did a Rorschach inkblot test.

JAD: Wow. What was the point of this study?

SEAN: Well, originally it was just to pinpoint the precursors to heart disease, but over time the study went way beyond that, and the researchers started asking all sorts of other questions.

JOSEPH GALLO: Questions about depression, anxiety.

SEAN: Fifty years of this study, and the doctors are getting older and older and ...

JOSEPH GALLO: Social support, retirement.

SEAN: ... at a certain point about 15 years ago, Joe and the other researchers start to ask these doctors about death.

JOSEPH GALLO: So if you have that paper in front of you?

SEAN: Yeah, hang on.

SEAN: Essentially, what they did was they presented the doctors, many of whom are now in their 60s, 70s and 80s, with the following scenario.

JOSEPH GALLO: What scenario is there?

SEAN: It says ...

SEAN: And it goes something like this. So say you have brain damage or some brain disease that can't be cured, you can't recognize people, you can't speak understandably and you're in this condition for a long time.

ROBERT: Like you're brain dead.

JOSEPH GALLO: Well, you're not brain dead but it describes maybe a scenario that's like severe dementia.

SEAN: And then it says, "Indicate your wishes regarding the use of each of the following medical procedures."

JOSEPH GALLO: There's a list. Ten. CPR, IV fluids, major surgery.

SEAN: There's a bunch of them.

JAD: So the question they're asking is if I'm in this terrible situation would I want these things?

SEAN: Would you agree to have these things done to you if it came down to it?

JOSEPH GALLO: Right.

JAD: Okay.

SEAN: So what would you say, as an example?

ROBERT: You're asking us now?

SEAN: Yeah, yeah. And I also put the question to a bunch of people on the street.

SEAN: Excuse me, sir. My name's Sean Cole. I'm a reporter with ...

ROBERT: Give me one.

SEAN: Like, so CPR for example. So your heart stops. CPR.

JAD: Would I want CPR?

MAN: Yes.

ROBERT: Yes. I want somebody to do that.

MAN: Yes.

WOMAN: Sure.

WOMAN: Yes.

MAN: Yes.

MAN: Well yes.

JAD: Seems like a no brainer.

SEAN: What about mechanical ventilation? It's a breathing machine.

ROBERT: A breathing machine.

SEAN: You're gonna die if you don't get it.

ROBERT: Well ...

MAN: Maybe.

JAD: Then yeah. Yeah, okay.

WOMAN: Yes.

MAN: Yes.

WOMAN: Sure.

WOMAN: Yeah, I wouldn't say don't do it. Yeah.

JAD: You remember all of them?

SEAN: Kidney dialysis?

JAD: Yes.

MAN: Yes.

ROBERT: I think so, yes.

SEAN: A feeding tube?

MAN: Yes.

MAN: Yep.

SEAN: Major surgery?

WOMAN: I don't know.

JAD: Like a gallbladder operation? If we're just talking about the gallbladder ...

SEAN: Gallbladder, sure.

JAD: Yeah.

SEAN: Antibiotics?

WOMAN: Yeah.

JAD: Totally.

MAN: Sure.

WOMAN: Sure.

SEAN: IV hydration?

WOMAN: Yes.

MAN: Yes.

ROBERT: Obviously.

SEAN: You would want all that?

WOMAN: Yeah!

ROBERT: Yes, yes and yes.

SEAN: That's what most people say. They want most everything. Maybe not some of the super-invasive stuff but generally, yes.

JAD: Okay.

SEAN: On the other hand, you ask the doctors what they want, same situation, brain dead or brain injured whatever, do they want CPR?

JOSEPH GALLO: 90 percent say no, they would not want CPR.

JAD: Really?

ROBERT: Really?

JAD: 90 percent?

ROBERT: 90? Whoa!

SEAN: Yeah. I mean, and I asked a bunch of doctors at a vascular health conference here in New York.

SEAN: Each of the following medical procedures.

SEAN: They said the same thing.

SEAN: CPR?

DOCTOR: No CPR.

DOCTOR: No.

DOCTOR: No CPR.

DOCTOR: No CPR.

JOSEPH GALLO: And almost 90 percent wouldn't want ventilation.

DOCTOR: No.

JOSEPH GALLO: Or dialysis.

DOCTOR: Definitely not.

DOCTOR: No, no, no.

JOSEPH GALLO: 80 percent would not want surgery.

DOCTOR: No.

JOSEPH GALLO: 80 percent would not want invasive testing.

DOCTOR: No, no.

JOSEPH GALLO: Almost 80 percent wouldn't want a feeding tube.

JAD: What?

DOCTOR: No.

JOSEPH GALLO: Or a blood product.

DOCTOR: No.

JOSEPH GALLO: Antibiotics, 60 percent would say ...

DOCTOR: No.

JAD: Really?

JOSEPH GALLO: IV hydration, about 60 percent.

JAD: Say no?

JOSEPH GALLO: They don't.

DOCTOR: Probably not.

JOSEPH GALLO: And then pain medicine is the one that's a bit different.

SEAN: The actual item on the survey reads, "Would you opt for pain medications, even if they dull the consciousness and indirectly shorten my life?"

JOSEPH GALLO: There, 80 percent of them say ...

DOCTOR: Yes.

DOCTOR: Yes.

DOCTOR: Yes.

DOCTOR: Pain reliever? Yes.

DOCTOR: Absolutely.

DOCTOR: Yes.

DOCTOR: Yeah.

DOCTOR: More.

DOCTOR: Painkiller, yes.

DOCTOR: Yes.

DOCTOR: Pain medication, yes.

JAD: So pain medication, that's all they want?

SEAN: For the most part, yeah.

ROBERT: Why would there be such a big gap between doctors and patients?

SEAN: In terms of how they want to end their life?

ROBERT: Yes.

SEAN: Well ...

SEAN: Hi, is that you?

KEN MURRAY: It's me.

SEAN: Great to meet you.

KEN MURRAY: You also, Sean.

SEAN: How are you doing?

SEAN: ... it started to become clear to me when I talked with Ken Murray. He's also a doctor.

SEAN: And you're in your doctor whites here.

KEN MURRAY: I thought I'd impress you. [laughs]

SEAN: I met up with him at a hospital in Los Angeles. He's written a bunch of articles now about how doctors want to die.

KEN MURRAY: This exact question was asked.

SEAN: So I asked him, like, why is there this difference, you know, particularly with something like CPR?

SEAN: What is it that doctors know that we're not aware of?

KEN MURRAY: Well, we know that CPR is basically pretty terrible as an intervention. It basically doesn't work very well. And people just don't believe that. They just can't believe it.

SEAN: And for a very good reason. There was a study done in 1996 about how many people survive CPR intervention on ER, Chicago Hope, Rescue 911. It's '96, those were hot shows then. And so the researcher watched all of these medical dramas and recorded what the result was.

[ARCHIVE CLIP: Come on, you can do it! Come back to us, Dawn! Do it! Come on! Two, three, four.]

KEN MURRAY: And the answer was 75 percent of the time people ...

[ARCHIVE CLIP: Come on. Come on. Okay, get the oxygen. Easy breaths.]

KEN MURRAY: ... were revived.

[ARCHIVE CLIP: Come on, nice easy breaths.]

KEN MURRAY: It worked 75 percent of the time.

[ARCHIVE CLIP: Easy breaths. Easy breaths, Dawn.]

KEN MURRAY: The actual number is more like eight.

JAD: Eight percent?

SEAN: Roughly eight percent survive to at least a month.

JAD: Wow!

KEN MURRAY: And in fact, it's worse than that.

SEAN: Here's how that eight percent breaks down.

KEN MURRAY: When you actually break it down, there was a fellow who did a study in 2010. He looked at 95,000 cases. Actually, more than that. I think it was all the cases in Japan that year. And what he found was that about three percent had what you would call a good outcome, that is return to a meaningful quality of life.

SEAN: You and me sitting here talking and eating sandwiches?

KEN MURRAY: Exactly. About the same number ...

SEAN: Three percent or so.

KEN MURRAY: ... ended up in a chronic vegetative state. Not quite brain dead, but pretty close.

SEAN: And the final two percent ...

KEN MURRAY: Were in some sort of intermediate level. Not good, but they weren't comatose. Everybody else was dead. That's the reality of it. And we physicians, we know that. We've actually done CPR. We have actually laid hands on the chest.

SEAN: Here's something I didn't know. Ken says that when you do CPR, you often end up cracking the person's ribs.

ROBERT: Wow!

SEAN: And yet that, according to Ken, is kind of mild in terms of some of the things that doctors put patients through.

KEN MURRAY: I think a lot of times we're doing things to people that we wouldn't do to a terrorist.

SEAN: Is that true or is that overstated?

KEN MURRAY: I'm not kidding.

SEAN: Like what kinds of things?

KEN MURRAY: Well, paralyzing somebody so that you cannot move, which you generally have to do when you put a person on a ventilator, a breathing machine, a respirator. When you put somebody on one of these machines it breathes for you, but the problem is you'll fight it because you'll have your own rhythm. So what happens is you have a person that is fighting, fighting, fighting, fighting, and you can't get air in and out of them, so you paralyze them.

SEAN: So they stop fighting. You know, they can't move.

KEN MURRAY: But it doesn't mean they're asleep. They're not asleep. They are completely helpless. And yet they're aware of everything that's going on around them.

SEAN: Sounds nightmarish, actually.

KEN MURRAY: Yeah. Yeah.

SEAN: Ken took me through a bunch of different situations from congestive heart failure to lung disease and pancreatic cancer, where he feels basically that the treatment is worse than the actual disease, what you have. It may be prolonging, but not for very long, and the life that you have left is misery.

KEN MURRAY: Right. Right.

SEAN: In fact, Ken says the colleagues of his, other doctors ...

KEN MURRAY: They'll turn to me in the ICU, and they say, "If you find me like this, kill me." And they're not kidding.

SEAN: He says there are doctors who wear medallions with the words, "No Code" stamped on them, which just means "Don't resuscitate me." He's even seen tattoos that say "No Code."

JAD: Okay. Can I talk to you now?

NAJI ABUMRAD: Yes.

JAD: Do you have any idea—come on! Turn that off!

JAD: Wait, Sean, can I just break in for one second?

SEAN: Yeah.

JAD: Because while you were reporting this piece, a very strange coincidence happened to me. I was visiting my dad, and after dinner one night he sits me down and he says, "I have something important I want to tell you. I've signed an advanced directive, which basically means if I end up in the hospital terminally ill or something, I don't want a lot of medical stuff done to me." I had not told him about your story at all.

SEAN: Really?

JAD: Yeah.

SEAN: So it was just out of the blue?

ROBERT: And he shows you a piece of paper? Or ...

JAD: No, not then. But I just saw him a couple of days ago and I asked him to read it to me because I hadn't actually seen it yet.

JAD: What does it say?

NAJI ABUMRAD: It says, "I direct that medical care be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications."

JAD: You can skip over that paragraph.

NAJI ABUMRAD: "I authorize the withholding of artificially-provided food, intravenous fluids and other nourishments."

JAD: "If I cannot give directions regarding my medical care, I intend that my family physicians honor this declaration as a final expression of my legal right to refuse medical care, and I accept the consequences of that refusal." Huh. So pain medication is all you really want?

NAJI ABUMRAD: Yeah, to keep me comfortable.

JAD: So—what was I saying? Sounds like the baby's crying. So you—it sounds like why wouldn't you want artificially-provided food, intravenous fluids or other nourishment?

NAJI ABUMRAD: That's my choice.

JAD: I know, but that doesn't sound like it's that much of an intervention, really.

NAJI ABUMRAD: It is an intervention to sustain life unnecessarily, if I should ever have a terminal condition.

JAD: Would you want CPR done?

NAJI ABUMRAD: If I have a choice, the answer is no.

JAD: But wouldn't you want Mom or I to be in a position where we can make the decision?

NAJI ABUMRAD: I mean, what if you conflict?

JAD: Like, she feels one way and I feel another?

NAJI ABUMRAD: Yeah.

JAD: He told me this is one of the worries that doctors have, that they'll talk to the patient or the patient's family, explain the situation carefully and everyone's agreed no more interventions. But then a random family member will just show up, you know, like a cousin or an estranged son or daughter, maybe carrying a lot of guilt, and they're like, "No doc, you have to do whatever it takes."

NAJI ABUMRAD: At the end of the day, I give the option to the patient and to the family to make a decision. That's what I have to do.

JAD: Except in this case, the patient is him.

JAD: But by having this, it means we have to honor this, right? We can't have our own feelings about it.

NAJI ABUMRAD: You can have your own feelings, but you still have to honor this.

JAD: But the thing that gives me pause is that I mean, you're a doctor, your job is to prolong life and to sustain life, and you choose not to when it comes to your own life.

NAJI ABUMRAD: Nobody said my job is to sustain life. My job is to sustain life when it is possible. It is not to sustain life when it's futile, and if you're going to sustain my life on a respirator, I don't want it. That kind of life, I do not want.

JAD: More than anything, the thing he wanted to make sure of is that he does not die in a hospital. He definitely does not want to die at the place where he works.

SEAN: That's something that came up a few times among the doctors at the conference that I went to.

TIM RYAN: I think I don't want to die in a hospital bed.

JAD: This is Tim Ryan, a resident at Cleveland Clinic.

SEAN: Why not?

TIM RYAN: Because I see patients and patients' families suffer tremendously, and I think we do a poor job of communicating futility to them. I don't know how to communicate that effectively. I don't know how to do it better. It's a difficult thing to bring up to the family. You know, how do you tell them your grandfather is not going to get better? We can keep him alive for a few weeks or a few months, but he's probably gonna have a tracheostomy and a feeding tube, a catheter in his bladder, and then he'll get bedsores and slowly deteriorate. I think we can focus on, you know, extending a life that has some quality so they can interact with their family, but once that's gone I don't know that we do much benefit.

SEAN: That sounded great. That was perfect. Why don't you say that?

TIM RYAN: I don't know. You have to have a sense that people want to hear that.

SEAN: No one would want to hear that, but they would need to hear it.

TIM RYAN: It's a little bit presumptuous.

SEAN: I mean, you can't tell someone not to hope. You can't pressure them to just let go of their loved one, and obviously you can't refuse to provide care.

JAD: You know though, there is one thing that struck me there talking to my dad. There's a question that patients will sometimes ask that can be a kind of bridge between doctors and patients. Very often, he says, when people are in the middle of this decision, they'll turn to him and they'll say, "Doc, what would you do if this was your mother or father?" And he says when they ask the question that way, it creates an entirely different conversation. He can say, "Here's what I would honestly do." Or in fact—and I did not know this. "Here's what I actually did."

NAJI ABUMRAD: It happened with my parents, when my father fell and developed complications as a result of the fall.

JAD: He says he called the doctor and told them no more medical interventions.

NAJI ABUMRAD: And he ended up dying comfortably. Same thing happened with my mother. I had discussed it with my mother and my father when they were not sick. This was a plan. I can tell you, in 90 percent of the patients that I see, such planning doesn't happen.

KEN MURRAY: I had a habit for most of my career when I'd have a new patient come in, particularly over the age of 50, I'd ask him, "How do you want to die?"

SEAN: This is Ken Murray again.

KEN MURRAY: A lot of them would give me a funny look. "That's an odd question for a doctor to be asking me." I said, "Well, you know, it's the one thing we can be sure of that's gonna happen eventually, and I want to make sure it happens the way you want." And so people, you know, the typical answer is, "Well, I'd like to die in my sleep, you know, painlessly."

MAN: The fastest way without any pain.

MAN: Peaceful.

WOMAN: Without pain and with friends.

KEN MURRAY: Which is how most people answer the question.

SEAN: Doctors and non-doctors.

WOMAN: With the least amount of pain and not drag it on.

MAN: Swiftly and painlessly.

KEN MURRAY: Well, what is that? I mean, what actually is that? That's usually a heart attack or a stroke, something of that nature, that happens just like that, and you're gone.

SEAN: And that's what we and our doctors are essentially doing everything in our power to avoid. So, like, when you ask people in the abstract, they're saying ...

MAN: How do I want to die? Peacefully.

SEAN: "I want to die peacefully, I want to die in my sleep," and everything like that. But when you ask them the specifics, you hear, "No. Pound on my chest, stick a tube down my throat." So it's this paradox.

ROBERT: It sounds to you like a paradox, but think about it. It could be—it's so, so healthy, to do both even at the same time. It's healthy to want to stay, and it's healthy to know how to be ready to go. I was listening to a Fresh Air sort of retake, and they had Maurice Sendak on the air, who died not too long ago. Before he died, he was on Fresh Air.

JAD: It was an amazing interview.

ROBERT: Yeah. And Terry Gross was talking to him, and he's sitting there in his Connecticut house looking out the window at a tree. And he says to Terry, "I am so in love with the tree and the beauty of it, and my chance to keep it company just a little while longer, and I want to stay. And every extra day I get is a day that's precious to me and makes me want to stay even harder." But, he says to Terry, "I am ready to go when it's time. I've made myself ready." And that—that compromise you make with yourself, to love it with your whole soul, and yet at the same time say, "I'll know when it's over, and I'm composed enough and prepared enough to take my exit," that's what a good death is.

JAD: Thank you, Sean Cole.

SEAN: You're welcome.

ROBERT: This is Sean Cole's—I mean, it's not his last appearance here but this is the last time he's on our full paycheck.

JAD: Yeah.

ROBERT: He's going off to host many things and be a reporter in other places.

JAD: Yes, it is a kind of death really.

SEAN: It's nothing like a kind of death.

ROBERT: A good death, though. It means, Sean, that you come back here regularly.

SEAN: I will. I will haunt you all.

JAD: You better.

SEAN: Special thanks to everybody at the VEITHsymposium on vascular health.

ROBERT: And to our doctors in this case, Joe Gallo and Ken Murray.

JAD: I'm Jad Abumrad.

ROBERT: I'm Robert Krulwich.

JAD: Thank you guys for listening.

[LISTENER: Hey, this is Glenn.]

[LISTENER: And Raymond.]

[LISTENER: And Reagan.]

[LISTENER: We're listeners from San Marcos, Texas, and here we're going to read the credits. Radiolab is supported in part by the National Science Foundation, and by ...]

[LISTENER: The Alfred P. Sloan Foundation, enhancing public understanding of science and technology in the modern world.]

[LISTENER: More information about Sloan at www.sloan.org.]

[LISTENER: All right, thanks. We did it!]

 

-30-

 

Copyright © 2024 New York Public Radio. All rights reserved. Visit our website terms of use at www.wnyc.org for further information.

 

New York Public Radio transcripts are created on a rush deadline, often by contractors. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of programming is the audio record.