Lots of people will take any treatment offered. Indeed I would. That's a perfectly acceptable approach.
Yes, medical treatments are improving and hanging on is a good approach cause something may be around the corner.
I don't think the article is advocating for no treatment ever.
I think it is advocating for a balanced understanding of what treatment looks like, and balances that with quality of life. And indeed balances your age as well.
If I'm 80, I'm (somewhat) less concerned with length of life, and more concerned with quality. If I'm 50 that's a different equation.
It's very much a personal choice, but to make a choice you have to have information. And it's helpful if you can make the choice in a calm relaxed environment. Both can be missing immediately after hearing a diagnosis.
The point is that medical intervention is usually desired. But equally there's a place for acceptance and contentment.
The father of a good friend passed away recently from a brain cancer. He was a doctor, but atypically accepted every treatment available. His last 3 years were spent in surgery or sick from chemo, did not have one good day after his initial diagnosis. If he could have gone back I'm sure he would have decided not to be treated.
You might not want it for yourself but many people, especially health professionals in my experience, will take a smaller but less painful lifespan over a chance to live longer through horrible treatments.
Agreeing with your overall sentiment, but this caught my eye:
> If I'm 80, I'm (somewhat) less concerned with length of life, and more concerned with quality. If I'm 50 that's a different equation
Why is that? Is quality less important at 50? Would you be more willing to endure suffering if you are younger? Why? I'm thinking that no matter age, people would generally like to avoid a painful death. Maybe it's because it feels more likely to "beat this thing" when you are younger, and then still potentially have decades ahead of you?
By 80 most people have reconciled with the idea that they don't have too many years left even in the best of conditions. There's no hope of extending life, and there's little to look forward to, they already lived through all the important milestones they could realistically see. Quality is all that's left to hope for.
At 50 they still can still hope for recovery and a life beyond that. They have a lot of moments and milestones ahead of them, at least with family and loved ones - see their kids graduate, get married, or have their own children. So if the hope is stronger than the pain, they'll sacrifice the quality of life.
> By 80 most people have […] already lived through all the important milestones they could realistically see.
That’s at least partially culturally determined. As the healthy live expectancy creeps up slowly, I expect that idea to change. There’s some truth in the saying “50 is the new 40”
Yeah, it is a big difference to undergo aggressive treatment at 50 vs. 80. Not just because of the potential years or months gained, but also because older bodies don't heal that well, or at all.
This is something that may be revolutionized through regenerative medicine, but hasn't so far.
I had cancer, it came back twice in 5 years, but now I'm 10 years out from the last time and my odds are good. Just mentioning it, in case it's helpful to hear a positive anecdote.
Sending my hopes for your recovery. You're right that new research is yielding fruit, but I don't have to tell you that.
Last week one of my patients with preterminal NYHA Stage IV cardiac failure looked into euthanasia.
He found predictably that it is now legal in my country but takes months and formidable legal resources to obtain it. Legalisation of euthanasia has, as everyone in the field warned multiple times, made it much harder to obtain and now requires a lot of time, effort and money.
The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it. The potential legal penalties for not getting the paperwork right, include loss of employment, deregistration and homicide charges. So now virtually no doctor wants to be involved for any amount of money.
So I told him how to contact the local palliative care unit when he decides to die, gave him documentation attesting to his preterminal , incurable status and taught him the magic words to almost instantly access that terminal, euthanising, life ending dose of mist. morphine...
"I have breathlessness and bone pain"
Also told him never again to say the word "euthanasia" to anyone, unless he wants a ride on the endless merry-go-round of legal paperwork.
Placing the hands in the abhaya mudra is optional...
If I’m understanding correctly, it was already quasi-legal through a loophole, but formally legalizing it made the loophole much trickier to use?
That does sound frustrating. I hope they simplify the legal rails… having to wait around in pain waiting for multiple rounds of paperwork to clear sounds terrible.
As the article points out, CPR really is oversold. I was a volunteer firefighter and did CPR multiple times, none of those people survived. I watched (and listened) as firefighters did CPR on my wife after she had a massive heart attack, hanging on to some hope but knowing deep down it was futile. But they transported her to emergency anyway.
I watched my father slowly die from sepsis that began with an infection in a toe. Surgery to improve leg circulation failed and his toe was amputated. The antibiotics not only induced the sepsis but led to a C. difficile infection. His mind deteriorated almost overnight. My mom couldn't make the decision to end care and place him in hospice, so the decision was passed to me. He had made his care wishes clear in writing, so while it was a hard decision, I knew it's what he wanted. He died less than a day later.
I'm working on my own care directives so my kids know exactly what to do when it's my time. With luck, they'll be able to ensure those directives are followed.
I'm a physician, an old one. We're lucky to live as long as we do, but life will end. The article emphasizes the value of dying peacefully. Sure, that's how we want it to be, but we have to make it known to assure it goes that way.
Don't know what happens elsewhere, but every time I see a doctor someone asks if I have a signed, notarized directive. Yes, I've done that, but so should everybody else concerned about the issue.
I have asked aged patients the same question. More than not the answer is "no". Why haven't you? Various versions of "on my list of things to do". We can't really predict future events, in our own interests best to be prepared. Some will take the hint, more than not, people procrastinate.
At least I've done what I can do, but we can't save people from themselves. Maybe people in healthcare are more aware of what's at stake, but everyone has the option to make it as clear as possible their wish (no, their demand) to die in peace.
>At least I've done what I can do, but we can't save people from themselves.
Why should doctors NEED to save people from themselves?
The default should be what the people in the industry have learned, with full permission to say "For myself, I have written a legally binding document that this is my personal wishes. I suggest you make that decision for your loved one, too."
Patients have the ability to ask for more, but there shouldn't be a constant need to save people from inadvertently choosing risky/painful low payoff medical care!
It is (mentally) painful to think about that this life is going to end. And even more (mentally) painful to think about the consequences of a (physically) painful end. The mind goes to great lengths to avoid pain.
Plus, society doesn't exactly create a culture in which this kind of talk and preparations are encouraged.
This article is making a LOT of "convenient" assumptions.
For all we know, the more likely scenario is that Charlie, like a sizeable percentage of his doctor peers, was burnt out, tired, and depressed, did not really have an overwhelming (some might say "healthy") desire to survive (in fact, perhaps quite the opposite), and saw the cancer as a non-undignified quick "way out".
Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
I have no objection regarding the choice he made, but let's not glorify it as the "natural" thing to do either. This narrative is harmful to people who "do" desire to survive but are scared, which may then prevent them from making a dispassionate decision regarding their care.
This is an interesting point and the article should definitely take these factors into account.
It's indeed very worrying what we ask medical professionals to put themselves through for their jobs. I think we can all agree that having a well rested doctor or nurse would be preferable over a stressed/tired one. The amount of hours and night shifts that (young) doctors have to do and the extreme competitiveness of the field (partly) drives this.
I understand that it would drive wages down (somewhat) if we educated more doctors and obviously we shouldn't lower our standards substantially but it seems like everyone involved would benefit from this.
A friend of mine, whose a doctor, told me once that the best way to ask for medical advice is to ask the doctor what he/she would recommend for their own sister/brother. Siblings are close enough that he would not want them to suffer unnecessarily but it eliminates the personal factors. Obviously it differs per doctor but in my experience it usually leads to a good conversation about the trade-offs for medical care.
> Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack... He explained to me that he never, under any circumstances, wanted to be placed on life support machines again.
> 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.
It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
> It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment
Is it? One action is reversible and the other is not. And it's not very rare that moral systems treat an action and its opposite in different ways (cooperating with police vs hindering, rendering aid vs withholding aid, etc).
There is a huge unspoken blind spot for a terminal hospice patient. The medicine cabinet just opens up. My dad asked the doctor exactly how much of what he shouldn't take if he didn't want a quick easy death, and the doctor just told him. He didn't end up using it but it was a comfort to him.
The amount of morphine available to the patients on hospice that I have known has made it very clear what the actual intent of those scripts is.
Granted, my sample size of 6 isn't great, and 3 were in terrible pain so it made sense for them, but they had ALL the opiates. . . One had liquid injectable morphine in case he couldn't swallow. He had no issues with swallowing and wasn't in pain.
I wanted to ask the doctor if the intent was to allow a calm end, but chickened out.
This reminds me of an interview with neurosurgeon and author Henry Marsh who had prostate cancer.
He described how he's arranged to end his own life should he get alzheimer's or dementia as he didn't want to waste away. But he explained that he has access to knowledge and things ordinary people don't.
I looked into this recently and it seems like it is basically impossible to pre-arrange assisted suicide for alzheimer's or dementia. Even in countries which allow death with dignity.
I find it very strange because it’s so common and I’m sure many people would prefer DWD in those circumstances.
The big problem with Alzheimer or dementia is related to consent and timing. People's memory dissolves pretty slowly. You'd almost certainly not want to be euthanized when you've just started forgetting where you've put your keys more often. Many would rather be euthanized than continue being a burden when they have stopped even remembering that bathrooms exist or who their family was. Between these extremes you can have many years, maybe even a decade, of good and bad days, weeks, months.
You can do it in Canada. Canada is on a euthanasia tear, and something like 3-4% of all deaths are by euthanasia or assisted suicide, and on track to reach double digits in the coming years. But euthanasia for dementia is a fine ethical line to navigate (Canada notwithstanding) because consent is either absent or suspect when the time comes.
shouldn't finding a way to kill yourself be pretty easy, even without legal DWD? you can overdose on OTC meds, or get a knife, or (in America) pick up a gun.
None of these things guarantee death and if you fail they come with some awful complications. Overdosing on Morphine is probably the easiest, most humane way to die.
> It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
It's not just the punishment but also how it's investigated / reported / charged. If somebody dies and there is just the slightest hint that another person was involved, by neglect or active help, police gets going right away. If somebody died "of natural causes" while suffering, or isn't even dead, just suffering, who is going to bring the charges? The suffering person won't. They are often unable to do so, that's why they are suffering in the first place. It's just an accepted part of being old and dying. Not even to speak of religious grounds (some of which consider suffering just being part of god's will).
If one lives in the US and feels strongly about it, they should file an Out-of-Hospital DNR and POLST with every local hospital. Also consider wearing or carrying official bracelets/necklaces (varies state to state).
But it is disingenuous to invoke "rightwing government", when a Franciscan friar was sneaking into the hospital trying to feed a starving woman [Terri], who was so hated by her husband that he would take extreme measures to get rid of her.
I have found it quite elusive to get a DNR properly executed. I could do all the other Advance Directives from home, and I could get them notarized without issue. But in my state, a DNR must be printed on a special hue of orange paper, and shit, if that isn't the most difficult step...
Also there are probably at least 12 facilities where it'd need to be filed, because who knows where the EMTs would haul me off to, around here. There are so many health care systems, not to mention the BH ones, which are quasi-medical.
> 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.
This point has been made by many medically trained people over decades. It's a very energetic intensive process, it cracks ribs. If it's not done promptly the brain has been starved of oxygen.
While I understand people not wanting to drag politics into everything I invite you to think about this and the situation of the senior senator for Kentucky.
> It's a very energetic intensive process, it cracks ribs.
I feel like lately this is becoming more common knowledge - but still something most people don't realize.
Part of it is probably the fact that it's impossible to depict "real" CPR in popular culture (movies, TV shows, etc) unless the production goes to extreme lengths to use a fake dummy. Even on The Pitt (which seems to make a point of being hyper realistic) I've seen them do "fake" CPR with shallow compressions.
so on Lost when Jack is really upset about Charlie, and he beats the shit out of his lifeless body, ... and it worked, did he do real or fake CPR? These comments make it sound very real.
Fake. You can't have fire without oxygen, but that doesn't mean you can't have oxygen without fire. Breaking someone's ribs doesn't necessarily mean you're performing CPR.
Yeah, akin to the Gell-mann Amnesia Effect, we notice a few things where we're experts but then forget everything else is likely just as bogus. Apparently one reason "Queen's Gambit" was a big deal was that most pop culture chess isn't just not very good chess (as you might innocently assume), it's literally nonsense. Like, pieces on the wrong squares, illegal moves, even simple continuity errors where pieces move between camera shots. So QG begins scoring points for chess fans when it remembers stuff like the White Queen starts on a White square...
> Early CPR (+AED if available) absolutely saves lives. Article is from 2011 by a family med doctor.
You have to provide a denominator to make this statement. 30-day survival for out-of-hospital CPR is 10%, and discharge from the hospital (let alone functional status) is even lower.
CPR is thus a great example of the OP's thesis that doctors refuse certain things based on their poor efficacy.
Okay. And what is the 30-day survival for cases where CPR would be otherwise indicated but are not performed?
It is a bit like complaining that jumping out of a burning airplane with a parachute is dangerous. Yes, it is. But jumping out of a parachute, or burning inside, is even more dangerous.
Did you read what you linked? It's not a study of the effects of cpr, it's a list of facts about cardiac arrest that occurs outside a hospital. It explicitly says cpr is life saving:
>Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed.
100%. CPR initiated within 2 minutes of cardiac arrest increases survival rate by 81%. The fact that CPR is rarely initiated so quickly (and thus survival rates are extremely low), says nothing about the efficacy of CPR. In the best cases where CPR is initiated < 2 mins, and AED shock within < 5mins survival rate can be as high as 50%.
It's important to get people to realize the benefits of early CPR and more people should be trained on how to do it, or else it won't be prompt and the outcomes will be worse. That's what the Red Cross and AHA promulgate to the public, in so many words.
I've never heard the term "load-bearing" used outside of the civil engineering world until the more recent versions of Claude suddenly decided everything was "load-bearing".
Did you internalize Claude terminology, use Claude to write/translate your post, or lead Claude into temptation by being the OG?
Asking out of genuine curiosity and not at all trying to throw shade.
"Load bearing beliefs" is a thing in the podcast/YouTube world at a minimum. Perhaps you're not as online as some other folks (probably a good thing!).
I watch a lot of tech adjacent YT videos mostly. I really haven't heard this being used. So weird the different bubbles we all live in and just don't realize. Is the usage recent or historic? What contexts is it used in? Is it common in American English, British English, or one of the several other groupings?
I have heard it in the way that Claude uses it going way back. Since I have to use Anthropic models for work, and they use that term prodigiously, it's been added to the list of "perfectly fine phrases that have been ruined" to me. It's really frustrating too because I don't know what other phrase I would use.
I don't suppose you recall where you picked it up? I really am curious on this, regardless what all the downvoters happen to think. The linguistics that surface in the training mixed with the system prompts is really interesting. Annoying as well, but still interesting.
Technically not civil engineering but similarly enough in the home-reno space. You can knock down a retaining wall relatively willy-nilly but a load-bearing wall needs a replacement thought out ahead of time.
So extended to concepts it always seemed a natural fit. I think where I picked it up in this regard was when used to describe Religion, in that you don't necessarily need the religions we have to "fill the god hole" but you need something of similar fortitude in order to maintain balance. The idea is that you can't just remove religion and then not replace it because it bears so much weight.
It's funny you're being grumped at about it, but yeah "load-bearing" outside of civil eng is my "nails on a chalkboard" slop signal. Well, one of many.
My only point was that this article shouldn’t be considered authoritative, wanted to put it in perspective for someone surfing hn and just reading the comments
The person closest to me was saved by CPR after cardiac arrest (and cooling at the hospital), with no neurological deficits
I have a friend who had a spontaneous pneumothorax. He even wrote a song about it after he recovered.
I myself punctured and collapsed both lungs. My thinking is: if there's a reasonable chance I'll survive, go for it. If there's not, stop trying to prolong the inevitable. That said, when I had the accident they told my wife to get there as fast as she could because I was likely not going to make it, and that was thirty years ago. So: if they're confident I'm going to die, don't try to prolong it :-)
If CPR is done right ~10% will walk out of the hospital. But that's a big if! Must be near a trained bystander. AED is much better on shockable rhythms, ~70%. Unfortunately most out-of-hospital cardiac events occur in homes which rarely have access to a device.
In 2021, a drone-delivered AED was used to successfully shock a 71-year-old man back into a stable rhythm in Sweden. The drone delivered the AED in just over three minutes from a 911 call.
Studying years of emergency drone data back up the anecdotes. The AED gets there 10-15 min ahead of medics and boosts survival 70%.
No I have no more information than anyone else. But, even at normal response times he was incapacitated for more than 2-3 minutes before CPR and after that, reportage is divergent with frankly bizarre variances around talking to somebody and talking with somebody.
My mother died last month,I have seen that same costly futile care before when it was performed on my father two decades before, but we had no choice. Both were injected with a dozen drugs syringes and perforated with tubes, hooked up to machines.
Although I am somewhat healthy, yet looking at rocking 60 made me contemplate and feel contentment just upon reading about psilocybin for patients dealing with life-threatening diagnoses, end-of-life anxiety (plus a dozen documentaries and 2 on Netflix). Learning about it has offered me relief and lasting drop in existential distress, especially as it helps melt the ego into everything.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9833165/
As a doctor, I think we are prepared for our own death (not so much for illness though). Especially during the last days or months we know exactly what's happening. I agree that the less-care-but-less-side-effects way is chosen much more often by doctors for themselves and their close relatives (I personally administered to my mother opioid to accelerate death due to terminal cancer a couple of days before the expected end that would be tortuous).
For my end stage patients I advise full palliative analgesic and sedative therapy but usually against futile chemos and intubations. There is a discussion where ICU doctors and oncologists have to take part.
I don't know, that's why I'm asking! If I'm in that situation I hope this option is available to me, and want to know what to ask for.
If the answer is that it's illegal I'd know I can't ask this directly/explicitly (but maybe there's a "secret handshake" way of asking for it). If it is I'd know I can. I wish no harm to OP.
The patient must be hospitalised and the administration is justified as an analgesic, sedative and for heart failure when pressure, pulse and breath start to reduce. I believe any doctor whould agree after discussion with the relatives. The problem is the doctors rarely bring it to surface and the people don't know to demand it.
Here in the UK there is an ongoing debate happening more or less behind the scenes around the language that should be used for families of patients nearing end of life. The standard question is: Should we "do everything possible" to keep someone alive? The proposed better question is: Should we "allow natural death"? Any doctor understands intimately that these two questions are equivalent. Understandably, the average person doesn't. Why wouldn't you "do everything possible"? In most of these conversations the argument against just doesn't come up.
I really don’t agree here. The focus should be on combating the observational bias that is the cause of these decisions. The doctors remember the “futile” cares for the patients where it had the worst results. We’re wired to concentrate on the negative outcomes, and doctors are bathing in it.
I recently read the book Being Mortal by Atul Gawande, a doctor. He emphasized how terminal care should focus on quality of life instead of attempting to prolong it and making it awful.
Last year, my mom was diagnosed with Stage 4 cancer. My family largely agrees with this article: treatment was a mistake and likely worse than the disease (bar palliative care and a stent).
The headline we used in cancer education is about 38% of cancer cases are likely caused and perhaps preventable by modifiable lifestyle factors: Tabbaco, infections, alcohol, UV.
Widespread vaccination (HPV, Hep B/C etc) and precision prevention (genetic counseling and preventative interventions) add another layer of preventative opportunity, and could significantly move the needle inclusive of and beyond/above lifestyle factors.
This leaves a lot of room for change, but requires a changing of economic incentives and cultural factors: which are incredibly slow moving ships.
The next layer is early detection (pre-cancer and early cancer); and technology advancements look promising - multi-cancer blood tests like Galleri and whole-body MRI (Prenuvo, Neko, Midjourney) are scientifically and economically promising, but all commercially ahead of their time.
These two additional pots potentially provide another significant opportunity to reduce the burden where the cost-benefit on personal suffering makes sense.
I’d add as the last personal suffering cost-benefit promising intervention layer targeted immunotherapy (and perhaps to a lesser extent ADCs/smart-bombs), where many patients enjoy results without bearing equal or exceeding suffering. Though with smart bombs, the maths isn’t as convincing, and with both you’re heading into lower odds bets.
Ofcourse, many people are helped by classical chemo, but much of the time (and especially in later stages) you’re hoping to be the exception, and at this point, the population wide experience is in many cancer types net negative.
Many people pin there hopes on this last, narrow category of intervention for breakthroughs; and hopefully they come; but likely this hope, attention and capital is misplaced.
> 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 cardiopulmonary resuscitation (that’s what happens if CPR is done right).
I have been seeing so much anti-LUCAS-machine content on the internet lately; it is far too prevalent to be anything but an astroturfing campaign. From whence this meme?
On the spectrum or go gentle vs fight, I'd have to say, now is the time is history where "fight" makes the most sense.
This is not abstract for me. I have not one, but two forms of cancer.
Both were considered incurable when I was diagnosed.
Both have treatments now that, IN SOME PEOPLE, lead to remission.
I still don't know which group I am, but I'd be dead from either one by now, if I hadn't elected to treat.
New treatments, for SOME cancers are literally coming out monthly.
So the fact that you can't be cured today, does mean there won't be a better treatment by next year, if you can hang on.
I should find out soon on my more aggressive one. Either way, I plan on continuing to try.
The question to ask is: did those people who got remission do so because of the treatment, because of something else, or despite treatment?
It seems to me that much of modern chemotherapy is rather barbaric, but this is very much an outside view.
Wish you all the best, with medicine, or without.
Lots of people will take any treatment offered. Indeed I would. That's a perfectly acceptable approach.
Yes, medical treatments are improving and hanging on is a good approach cause something may be around the corner.
I don't think the article is advocating for no treatment ever.
I think it is advocating for a balanced understanding of what treatment looks like, and balances that with quality of life. And indeed balances your age as well.
If I'm 80, I'm (somewhat) less concerned with length of life, and more concerned with quality. If I'm 50 that's a different equation.
It's very much a personal choice, but to make a choice you have to have information. And it's helpful if you can make the choice in a calm relaxed environment. Both can be missing immediately after hearing a diagnosis.
The point is that medical intervention is usually desired. But equally there's a place for acceptance and contentment.
The father of a good friend passed away recently from a brain cancer. He was a doctor, but atypically accepted every treatment available. His last 3 years were spent in surgery or sick from chemo, did not have one good day after his initial diagnosis. If he could have gone back I'm sure he would have decided not to be treated.
Unless going back gets you to re-roll your dice then I'm sure they would still have done it.
You might not want it for yourself but many people, especially health professionals in my experience, will take a smaller but less painful lifespan over a chance to live longer through horrible treatments.
Agreeing with your overall sentiment, but this caught my eye:
> If I'm 80, I'm (somewhat) less concerned with length of life, and more concerned with quality. If I'm 50 that's a different equation
Why is that? Is quality less important at 50? Would you be more willing to endure suffering if you are younger? Why? I'm thinking that no matter age, people would generally like to avoid a painful death. Maybe it's because it feels more likely to "beat this thing" when you are younger, and then still potentially have decades ahead of you?
> Why is that?
By 80 most people have reconciled with the idea that they don't have too many years left even in the best of conditions. There's no hope of extending life, and there's little to look forward to, they already lived through all the important milestones they could realistically see. Quality is all that's left to hope for.
At 50 they still can still hope for recovery and a life beyond that. They have a lot of moments and milestones ahead of them, at least with family and loved ones - see their kids graduate, get married, or have their own children. So if the hope is stronger than the pain, they'll sacrifice the quality of life.
> By 80 most people have […] already lived through all the important milestones they could realistically see.
That’s at least partially culturally determined. As the healthy live expectancy creeps up slowly, I expect that idea to change. There’s some truth in the saying “50 is the new 40”
I think you've got it exactly right:
- what is the expected gain? Years+Quality
- what is the maximum gain? Years+Quality
The older you are the smaller your maximum gain of Years can be.
Yeah, it is a big difference to undergo aggressive treatment at 50 vs. 80. Not just because of the potential years or months gained, but also because older bodies don't heal that well, or at all.
This is something that may be revolutionized through regenerative medicine, but hasn't so far.
Pancreatic cancer caregiver here.
It's a battle, not a boxing match, that you're fighting. No shame in a battle chant or maybe even a battle cry.
I had cancer, it came back twice in 5 years, but now I'm 10 years out from the last time and my odds are good. Just mentioning it, in case it's helpful to hear a positive anecdote.
Sending my hopes for your recovery. You're right that new research is yielding fruit, but I don't have to tell you that.
Sending good wishes
Sending thoughts of remission through the aether. And wishing your tries become success.
Hero - keep fighting!
I think it's exactly this attitude which the article is about.
Of course I wish the best to whoever decides to fight. But fighting at any cost isn't the best advice.
Give us an update in twenty years please.
Keep fighting the good fight, Internet friend. I look forward to reading your remission comment one day.
if nothing works, try cryonics. Maybe AI-2040 is right and we'll be able to revive you in a few years.
The cryonics industry is an unbelievable scam. You habe watched too much scifi my friend.
Are you knowledgeable about this, and are you talking about the established institutions? If so please explain.
Last week one of my patients with preterminal NYHA Stage IV cardiac failure looked into euthanasia.
He found predictably that it is now legal in my country but takes months and formidable legal resources to obtain it. Legalisation of euthanasia has, as everyone in the field warned multiple times, made it much harder to obtain and now requires a lot of time, effort and money.
The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it. The potential legal penalties for not getting the paperwork right, include loss of employment, deregistration and homicide charges. So now virtually no doctor wants to be involved for any amount of money.
So I told him how to contact the local palliative care unit when he decides to die, gave him documentation attesting to his preterminal , incurable status and taught him the magic words to almost instantly access that terminal, euthanising, life ending dose of mist. morphine...
"I have breathlessness and bone pain"
Also told him never again to say the word "euthanasia" to anyone, unless he wants a ride on the endless merry-go-round of legal paperwork.
Placing the hands in the abhaya mudra is optional...
> The well meaning, naive proponents of legalisation of euthanasia have actually made things a lot harder for those who want it.
In your mind, what should have been done instead of legalizing it?
If I’m understanding correctly, it was already quasi-legal through a loophole, but formally legalizing it made the loophole much trickier to use? That does sound frustrating. I hope they simplify the legal rails… having to wait around in pain waiting for multiple rounds of paperwork to clear sounds terrible.
As the article points out, CPR really is oversold. I was a volunteer firefighter and did CPR multiple times, none of those people survived. I watched (and listened) as firefighters did CPR on my wife after she had a massive heart attack, hanging on to some hope but knowing deep down it was futile. But they transported her to emergency anyway.
I watched my father slowly die from sepsis that began with an infection in a toe. Surgery to improve leg circulation failed and his toe was amputated. The antibiotics not only induced the sepsis but led to a C. difficile infection. His mind deteriorated almost overnight. My mom couldn't make the decision to end care and place him in hospice, so the decision was passed to me. He had made his care wishes clear in writing, so while it was a hard decision, I knew it's what he wanted. He died less than a day later.
I'm working on my own care directives so my kids know exactly what to do when it's my time. With luck, they'll be able to ensure those directives are followed.
I'm a physician, an old one. We're lucky to live as long as we do, but life will end. The article emphasizes the value of dying peacefully. Sure, that's how we want it to be, but we have to make it known to assure it goes that way.
Don't know what happens elsewhere, but every time I see a doctor someone asks if I have a signed, notarized directive. Yes, I've done that, but so should everybody else concerned about the issue.
I have asked aged patients the same question. More than not the answer is "no". Why haven't you? Various versions of "on my list of things to do". We can't really predict future events, in our own interests best to be prepared. Some will take the hint, more than not, people procrastinate.
At least I've done what I can do, but we can't save people from themselves. Maybe people in healthcare are more aware of what's at stake, but everyone has the option to make it as clear as possible their wish (no, their demand) to die in peace.
>At least I've done what I can do, but we can't save people from themselves.
Why should doctors NEED to save people from themselves?
The default should be what the people in the industry have learned, with full permission to say "For myself, I have written a legally binding document that this is my personal wishes. I suggest you make that decision for your loved one, too."
Patients have the ability to ask for more, but there shouldn't be a constant need to save people from inadvertently choosing risky/painful low payoff medical care!
> Why haven't you?
It is (mentally) painful to think about that this life is going to end. And even more (mentally) painful to think about the consequences of a (physically) painful end. The mind goes to great lengths to avoid pain.
Plus, society doesn't exactly create a culture in which this kind of talk and preparations are encouraged.
This article is making a LOT of "convenient" assumptions.
For all we know, the more likely scenario is that Charlie, like a sizeable percentage of his doctor peers, was burnt out, tired, and depressed, did not really have an overwhelming (some might say "healthy") desire to survive (in fact, perhaps quite the opposite), and saw the cancer as a non-undignified quick "way out".
Doctors (and medical professionals more generally) rank among the highest in occupational risk of mental health disease, especially for things like addiction, alcoholism, generalised anxiety, ptsd, depression and suicide.
I have no objection regarding the choice he made, but let's not glorify it as the "natural" thing to do either. This narrative is harmful to people who "do" desire to survive but are scared, which may then prevent them from making a dispassionate decision regarding their care.
This is an interesting point and the article should definitely take these factors into account.
It's indeed very worrying what we ask medical professionals to put themselves through for their jobs. I think we can all agree that having a well rested doctor or nurse would be preferable over a stressed/tired one. The amount of hours and night shifts that (young) doctors have to do and the extreme competitiveness of the field (partly) drives this.
I understand that it would drive wages down (somewhat) if we educated more doctors and obviously we shouldn't lower our standards substantially but it seems like everyone involved would benefit from this.
A friend of mine, whose a doctor, told me once that the best way to ask for medical advice is to ask the doctor what he/she would recommend for their own sister/brother. Siblings are close enough that he would not want them to suffer unnecessarily but it eliminates the personal factors. Obviously it differs per doctor but in my experience it usually leads to a good conversation about the trade-offs for medical care.
> Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack... He explained to me that he never, under any circumstances, wanted to be placed on life support machines again.
> 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.
It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
> It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment
Is it? One action is reversible and the other is not. And it's not very rare that moral systems treat an action and its opposite in different ways (cooperating with police vs hindering, rendering aid vs withholding aid, etc).
There is a huge unspoken blind spot for a terminal hospice patient. The medicine cabinet just opens up. My dad asked the doctor exactly how much of what he shouldn't take if he didn't want a quick easy death, and the doctor just told him. He didn't end up using it but it was a comfort to him.
The amount of morphine available to the patients on hospice that I have known has made it very clear what the actual intent of those scripts is.
Granted, my sample size of 6 isn't great, and 3 were in terrible pain so it made sense for them, but they had ALL the opiates. . . One had liquid injectable morphine in case he couldn't swallow. He had no issues with swallowing and wasn't in pain.
I wanted to ask the doctor if the intent was to allow a calm end, but chickened out.
Amazing how frequently people die after they’re turned over right when the family is all together.
Amazing and appreciated.
Open secret.
Cowardice of the system, society, that doesn’t allow practitioners to discuss this.
Leads to scary grey areas, actually.
> Cowardice of the system, society, that doesn’t allow practitioners to discuss this.
This depends on where one lives. Where I am (New Zeland), the arguments getting it into law were pretty grim.
Serious stuff is serious!
Ignoring addressing it doesn’t make it go away - just forces it into the shadows.
Exactly. Abortion being the example that immediately comes to mind.
This reminds me of an interview with neurosurgeon and author Henry Marsh who had prostate cancer.
He described how he's arranged to end his own life should he get alzheimer's or dementia as he didn't want to waste away. But he explained that he has access to knowledge and things ordinary people don't.
I looked into this recently and it seems like it is basically impossible to pre-arrange assisted suicide for alzheimer's or dementia. Even in countries which allow death with dignity. I find it very strange because it’s so common and I’m sure many people would prefer DWD in those circumstances.
The big problem with Alzheimer or dementia is related to consent and timing. People's memory dissolves pretty slowly. You'd almost certainly not want to be euthanized when you've just started forgetting where you've put your keys more often. Many would rather be euthanized than continue being a burden when they have stopped even remembering that bathrooms exist or who their family was. Between these extremes you can have many years, maybe even a decade, of good and bad days, weeks, months.
In Switzerland, there are four agencies - one treats foreigners as well (Pegasos Association)
You can do it in Canada. Canada is on a euthanasia tear, and something like 3-4% of all deaths are by euthanasia or assisted suicide, and on track to reach double digits in the coming years. But euthanasia for dementia is a fine ethical line to navigate (Canada notwithstanding) because consent is either absent or suspect when the time comes.
To me, it doesn’t seem strange at all because I’m thinking about how complicated the system would have to be to carry out such a directive.
shouldn't finding a way to kill yourself be pretty easy, even without legal DWD? you can overdose on OTC meds, or get a knife, or (in America) pick up a gun.
> DWD? you can overdose on OTC meds, or get a knife, or (in America) pick up a gun.
Someone with sound mind is likely to worry about what’ll be left for loved ones to clean up.
And someone suffering dementia/Alzheimer’s may well forget the plan.
None of these things guarantee death and if you fail they come with some awful complications. Overdosing on Morphine is probably the easiest, most humane way to die.
> It's interesting that our laws punish homicide with maximum criminal penalties, but the opposite (keeping someone alive against their wishes) seems to be assault and battery at worst, with much much lighter punishment.
It's not just the punishment but also how it's investigated / reported / charged. If somebody dies and there is just the slightest hint that another person was involved, by neglect or active help, police gets going right away. If somebody died "of natural causes" while suffering, or isn't even dead, just suffering, who is going to bring the charges? The suffering person won't. They are often unable to do so, that's why they are suffering in the first place. It's just an accepted part of being old and dying. Not even to speak of religious grounds (some of which consider suffering just being part of god's will).
Does the US have the concept of DNR (Do Not Resuscitate)?
Yes.
If one lives in the US and feels strongly about it, they should file an Out-of-Hospital DNR and POLST with every local hospital. Also consider wearing or carrying official bracelets/necklaces (varies state to state).
I'm neither a lawyer nor a doctor. :)
There was a "culture war" (the rightwing government intervening due to religious reasons) in the 2000's involving a "DNR"-esque case https://en.wikipedia.org/wiki/Terri_Schiavo_case
Let us not forget https://en.wikipedia.org/wiki/Karen_Ann_Quinlan
And also https://en.wikipedia.org/wiki/Jahi_McMath_case
But it is disingenuous to invoke "rightwing government", when a Franciscan friar was sneaking into the hospital trying to feed a starving woman [Terri], who was so hated by her husband that he would take extreme measures to get rid of her.
I have found it quite elusive to get a DNR properly executed. I could do all the other Advance Directives from home, and I could get them notarized without issue. But in my state, a DNR must be printed on a special hue of orange paper, and shit, if that isn't the most difficult step...
Also there are probably at least 12 facilities where it'd need to be filed, because who knows where the EMTs would haul me off to, around here. There are so many health care systems, not to mention the BH ones, which are quasi-medical.
Yes
> 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.
This point has been made by many medically trained people over decades. It's a very energetic intensive process, it cracks ribs. If it's not done promptly the brain has been starved of oxygen.
While I understand people not wanting to drag politics into everything I invite you to think about this and the situation of the senior senator for Kentucky.
> It's a very energetic intensive process, it cracks ribs.
I feel like lately this is becoming more common knowledge - but still something most people don't realize.
Part of it is probably the fact that it's impossible to depict "real" CPR in popular culture (movies, TV shows, etc) unless the production goes to extreme lengths to use a fake dummy. Even on The Pitt (which seems to make a point of being hyper realistic) I've seen them do "fake" CPR with shallow compressions.
so on Lost when Jack is really upset about Charlie, and he beats the shit out of his lifeless body, ... and it worked, did he do real or fake CPR? These comments make it sound very real.
Fake. You can't have fire without oxygen, but that doesn't mean you can't have oxygen without fire. Breaking someone's ribs doesn't necessarily mean you're performing CPR.
Yeah, akin to the Gell-mann Amnesia Effect, we notice a few things where we're experts but then forget everything else is likely just as bogus. Apparently one reason "Queen's Gambit" was a big deal was that most pop culture chess isn't just not very good chess (as you might innocently assume), it's literally nonsense. Like, pieces on the wrong squares, illegal moves, even simple continuity errors where pieces move between camera shots. So QG begins scoring points for chess fans when it remembers stuff like the White Queen starts on a White square...
Totally misleading. Early CPR (+AED if available) absolutely saves lives. Article is from 2011 by a family med doctor.
Overly aggressive resuscitation attempts are definitely a problem but context matters
> Early CPR (+AED if available) absolutely saves lives. Article is from 2011 by a family med doctor.
You have to provide a denominator to make this statement. 30-day survival for out-of-hospital CPR is 10%, and discharge from the hospital (let alone functional status) is even lower.
CPR is thus a great example of the OP's thesis that doctors refuse certain things based on their poor efficacy.
https://www.redcross.org/take-a-class/resources/articles/cpr...
> 30-day survival for out-of-hospital CPR is 10%
Okay. And what is the 30-day survival for cases where CPR would be otherwise indicated but are not performed?
It is a bit like complaining that jumping out of a burning airplane with a parachute is dangerous. Yes, it is. But jumping out of a parachute, or burning inside, is even more dangerous.
Did you read what you linked? It's not a study of the effects of cpr, it's a list of facts about cardiac arrest that occurs outside a hospital. It explicitly says cpr is life saving:
>Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed.
100%. CPR initiated within 2 minutes of cardiac arrest increases survival rate by 81%. The fact that CPR is rarely initiated so quickly (and thus survival rates are extremely low), says nothing about the efficacy of CPR. In the best cases where CPR is initiated < 2 mins, and AED shock within < 5mins survival rate can be as high as 50%.
https://newsroom.heart.org/news/bystander-cpr-up-to-10-minut...
I struggle square those numbers with the ones below, showing 11% survival (22% making it to hospital alive).
I can’t find a source for it, but I’m told that survival after an arrest in hospital is actually lower, due to the co-morbidities that patients have.
https://www.resus.org.nz/assets/OHCA_All_NZ_Feb23.pdf
"Early" is load-bearing. Even brief delays, just mere minutes, significantly decrease survival or positive outcomes.
https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.123.010...
It's important to get people to realize the benefits of early CPR and more people should be trained on how to do it, or else it won't be prompt and the outcomes will be worse. That's what the Red Cross and AHA promulgate to the public, in so many words.
I've never heard the term "load-bearing" used outside of the civil engineering world until the more recent versions of Claude suddenly decided everything was "load-bearing".
Did you internalize Claude terminology, use Claude to write/translate your post, or lead Claude into temptation by being the OG?
Asking out of genuine curiosity and not at all trying to throw shade.
"Load bearing beliefs" is a thing in the podcast/YouTube world at a minimum. Perhaps you're not as online as some other folks (probably a good thing!).
I watch a lot of tech adjacent YT videos mostly. I really haven't heard this being used. So weird the different bubbles we all live in and just don't realize. Is the usage recent or historic? What contexts is it used in? Is it common in American English, British English, or one of the several other groupings?
I have heard it in the way that Claude uses it going way back. Since I have to use Anthropic models for work, and they use that term prodigiously, it's been added to the list of "perfectly fine phrases that have been ruined" to me. It's really frustrating too because I don't know what other phrase I would use.
You could use the word "important"
Yeah the stupid machine could have picked "let us circle back" or something but nope.
I don't suppose you recall where you picked it up? I really am curious on this, regardless what all the downvoters happen to think. The linguistics that surface in the training mixed with the system prompts is really interesting. Annoying as well, but still interesting.
Technically not civil engineering but similarly enough in the home-reno space. You can knock down a retaining wall relatively willy-nilly but a load-bearing wall needs a replacement thought out ahead of time.
So extended to concepts it always seemed a natural fit. I think where I picked it up in this regard was when used to describe Religion, in that you don't necessarily need the religions we have to "fill the god hole" but you need something of similar fortitude in order to maintain balance. The idea is that you can't just remove religion and then not replace it because it bears so much weight.
"does some heavy lifting"
No. I do use the term.
I'm curious where you picked it up originally. I've been mystified why Claude started using it so much.
I’ve been using it in the tech space for many years now, no idea where I picked it up. Also this is the first I’ve heard Claude is using it!
It's funny you're being grumped at about it, but yeah "load-bearing" outside of civil eng is my "nails on a chalkboard" slop signal. Well, one of many.
What are the statistics for quality of life after CPR even if it saves the patients life? I think this is more what the article is about.
How has CPR (or CPR data) changed since 2011? What type of medicine do you practice?
My only point was that this article shouldn’t be considered authoritative, wanted to put it in perspective for someone surfing hn and just reading the comments
The person closest to me was saved by CPR after cardiac arrest (and cooling at the hospital), with no neurological deficits
I have a friend who had a spontaneous pneumothorax. He even wrote a song about it after he recovered.
I myself punctured and collapsed both lungs. My thinking is: if there's a reasonable chance I'll survive, go for it. If there's not, stop trying to prolong the inevitable. That said, when I had the accident they told my wife to get there as fast as she could because I was likely not going to make it, and that was thirty years ago. So: if they're confident I'm going to die, don't try to prolong it :-)
If CPR is done right ~10% will walk out of the hospital. But that's a big if! Must be near a trained bystander. AED is much better on shockable rhythms, ~70%. Unfortunately most out-of-hospital cardiac events occur in homes which rarely have access to a device.
In 2021, a drone-delivered AED was used to successfully shock a 71-year-old man back into a stable rhythm in Sweden. The drone delivered the AED in just over three minutes from a 911 call.
Studying years of emergency drone data back up the anecdotes. The AED gets there 10-15 min ahead of medics and boosts survival 70%.
AED: automated external defibrillator.
Do you know what is happening with McConnell? Because the news is everywhere from he's fine to he's dead.
Edit: this is not meant to be snarky. This is a real question.
No I have no more information than anyone else. But, even at normal response times he was incapacitated for more than 2-3 minutes before CPR and after that, reportage is divergent with frankly bizarre variances around talking to somebody and talking with somebody.
MY ex-wife who was a CNA had made it a point to me that she had a DNR. How or where, she never told me. Probably for the best.
My mother died last month,I have seen that same costly futile care before when it was performed on my father two decades before, but we had no choice. Both were injected with a dozen drugs syringes and perforated with tubes, hooked up to machines.
Although I am somewhat healthy, yet looking at rocking 60 made me contemplate and feel contentment just upon reading about psilocybin for patients dealing with life-threatening diagnoses, end-of-life anxiety (plus a dozen documentaries and 2 on Netflix). Learning about it has offered me relief and lasting drop in existential distress, especially as it helps melt the ego into everything. https://pmc.ncbi.nlm.nih.gov/articles/PMC9833165/
As a doctor, I think we are prepared for our own death (not so much for illness though). Especially during the last days or months we know exactly what's happening. I agree that the less-care-but-less-side-effects way is chosen much more often by doctors for themselves and their close relatives (I personally administered to my mother opioid to accelerate death due to terminal cancer a couple of days before the expected end that would be tortuous).
For my end stage patients I advise full palliative analgesic and sedative therapy but usually against futile chemos and intubations. There is a discussion where ICU doctors and oncologists have to take part.
> administered to my mother opioid to accelerate death
Isn't that illegal is most countries? Does it not count as doctor assisted suicide?
What are you hoping to get out of asking this question? It sounds like you already know the answer.
I don't know, that's why I'm asking! If I'm in that situation I hope this option is available to me, and want to know what to ask for.
If the answer is that it's illegal I'd know I can't ask this directly/explicitly (but maybe there's a "secret handshake" way of asking for it). If it is I'd know I can. I wish no harm to OP.
I believe it varies by state but typically must be administered by a doctor or hospice nurse.
The patient must be hospitalised and the administration is justified as an analgesic, sedative and for heart failure when pressure, pulse and breath start to reduce. I believe any doctor whould agree after discussion with the relatives. The problem is the doctors rarely bring it to surface and the people don't know to demand it.
Thank you for the through answer! I hope I remember what to ask if/when the time ever comes.
Causing death in the course of administering treatment is not illegal.
For someone in severe pain, it’s completely legal to offering increasing doses of morphine to treat pain even if it results in death.
Here in the UK there is an ongoing debate happening more or less behind the scenes around the language that should be used for families of patients nearing end of life. The standard question is: Should we "do everything possible" to keep someone alive? The proposed better question is: Should we "allow natural death"? Any doctor understands intimately that these two questions are equivalent. Understandably, the average person doesn't. Why wouldn't you "do everything possible"? In most of these conversations the argument against just doesn't come up.
I really don’t agree here. The focus should be on combating the observational bias that is the cause of these decisions. The doctors remember the “futile” cares for the patients where it had the worst results. We’re wired to concentrate on the negative outcomes, and doctors are bathing in it.
I recently read the book Being Mortal by Atul Gawande, a doctor. He emphasized how terminal care should focus on quality of life instead of attempting to prolong it and making it awful.
I worked for some years in cancer prevention.
Last year, my mom was diagnosed with Stage 4 cancer. My family largely agrees with this article: treatment was a mistake and likely worse than the disease (bar palliative care and a stent).
The headline we used in cancer education is about 38% of cancer cases are likely caused and perhaps preventable by modifiable lifestyle factors: Tabbaco, infections, alcohol, UV.
Widespread vaccination (HPV, Hep B/C etc) and precision prevention (genetic counseling and preventative interventions) add another layer of preventative opportunity, and could significantly move the needle inclusive of and beyond/above lifestyle factors.
This leaves a lot of room for change, but requires a changing of economic incentives and cultural factors: which are incredibly slow moving ships.
The next layer is early detection (pre-cancer and early cancer); and technology advancements look promising - multi-cancer blood tests like Galleri and whole-body MRI (Prenuvo, Neko, Midjourney) are scientifically and economically promising, but all commercially ahead of their time.
These two additional pots potentially provide another significant opportunity to reduce the burden where the cost-benefit on personal suffering makes sense.
I’d add as the last personal suffering cost-benefit promising intervention layer targeted immunotherapy (and perhaps to a lesser extent ADCs/smart-bombs), where many patients enjoy results without bearing equal or exceeding suffering. Though with smart bombs, the maths isn’t as convincing, and with both you’re heading into lower odds bets.
Ofcourse, many people are helped by classical chemo, but much of the time (and especially in later stages) you’re hoping to be the exception, and at this point, the population wide experience is in many cancer types net negative.
Many people pin there hopes on this last, narrow category of intervention for breakthroughs; and hopefully they come; but likely this hope, attention and capital is misplaced.
Previously...
How Doctors die. It’s not like the rest of us (2016) - https://news.ycombinator.com/item?id=28463482 - Sept 2021 (291 comments)
> 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 cardiopulmonary resuscitation (that’s what happens if CPR is done right).
I have been seeing so much anti-LUCAS-machine content on the internet lately; it is far too prevalent to be anything but an astroturfing campaign. From whence this meme?
Can confirm. Top of the article could be about my dad. Same flavor of cancer and everything.
Title should be corrected to the original:
---
How doctors die. It’s not like the rest of us, but it should be
---
Note to submitters: Check the title after submitting. If the HN algorithm mangled it as badly as this one, edit it!