Dying Patients and Ugly Politics

Death panels.  They are all the trend these days.
I went to Home Depot to look for some, but couldn\’t find any.  There was some drywall of doom, tiles of the abyss, and sheet rock of destruction, but no panels.  I guess the Obama administration has bought them all.

Honestly, I am not sure what the \”death panel\” fuss is about.  Everyone dies.  There are times it is a surprise, but many times it is expected.  When it is expected, shouldn\’t people plan for it?  Shouldn\’t we encourage people to plan for it?

The focus of a physician is twofold: to prolong life and to minimize suffering.  We practice preventive medicine to keep the person from avoidable pain and/or death.  The younger the patient is, the more we call their death things like tragic, pointless, and distressing.  We go to great lengths to save the life of someone who has many potential years ahead.

But there is a point when things change.  There is a point when the focus shifts from quantity of life to quality of life.  There is a time after which a death is no longer tragic, but instead the end of a story.  My focus as a physician shifts from trying to find and prevent disease, to maximizing function and minimizing pain.  When does this happen?  It depends on the health of the patient.  But eventually, ignoring one\’s inevitable end becomes more tragic than the end itself.

I had a man in my practice who had advanced Alzheimer\’s disease.  I cared for him before he started his decline, and so had a good chance to know both him and his family.  They were people of strong faith, accepting the hard things in life as being from the hand of God.  The children took their father\’s condition not as a horrible burden, but an opportunity to pay back the man who had given them so much.  There was no fear of illness or death.

His wife died fairly soon after I started caring for them.  He grieved greatly when she died, but was so surrounded with the love of their children that his grief was short.  He spoke often of her in subsequent visits, talking about her as if she was not far away.

As he became increasingly short in his memory, my relationship with their children grew.  You can tell a lot about people from their children, and these children were a dazzling crown of honor to these two lovely people.  They always came asking good questions, patiently dealing with their father\’s confusion, anxiety, and occasional outbursts.  Together we worked to maximize his quality of life.  When I suggested we stop cholesterol medication and cancer screening tests, they understood.  Our focus would not be on the length of life, but the quality of time they could spend with their father.

I was shocked, therefore, when the report of his admission to the hospital came across my desktop.  He had chest pains and some difficulty breathing.  In the emergency room, a plethora of lab tests, x-rays, and other studies were done.  The hospitalist physician on call felt there was a good possibility of heart attack or pulmonary embolism (blood clot to the lung).  My patient was sent to the ICU, where he underwent CT angiography, serial lab tests, and even a stress test to rule out heart problems.

I was mystified as I read these reports; the family clearly understood that prolonging his life wasn\’t the goal.  The patient was ready to die and join his wife, and the children were very comfortable talking about his eventual death.   These reports made absolutely no sense with what I knew of this man and his family.

He looked his normal self when he came in to my office for a hospital follow-up.  I questioned the daughter about the details of the admission, which she recounted carefully.  Then I paused and asked her, \”Can I ask you one more thing?\”

She smiled at me, \”Of course, Dr. Rob\” she said gently.

\”I was honestly a little surprised when I read about your father\’s admission to the hospital.  It seems like they pulled out all the stops, even putting him in the ICU.  Did they ask you if this is what you wanted?  I thought that you wouldn\’t want to be that aggressive.\”

She thought about what I said and a puzzled expression slowly appeared on her face.

\”Did you ask to have everything done, or did you just follow what the doctors at the hospital told you?\” I asked.

\”They didn\’t ask us.  We just did what they told us we needed to do.\” she said, now scowling slightly.

I explained to her that they need to make their wishes known in advance.  If they don\’t say anything, the doctors will assume that you agree with what they are doing.  As I told her this, she nodded and looked down sadly.

\”It\’s OK what you did\” I reassured her.  I patted her father on the shoulder and added, \”he looks great now.  I am glad I get to see him again.  I just want you to know what to do if it happens in the future.  You never know what will happen, and I\’d hate for him to suffer needlessly.\”

This one short hospital stay undoubtedly amassed a bill many times that of all my bills over the 12 years I saw him in my office.  My years of care, long conversations, and real personal connection built with this man and his family are worth only a fraction of a few days of unnecessary care.  This care was not demanded by the family.  It was not done because of denial or ignorance; it was because the family wasn\’t prepared for the mechanics of the hospital stay.  I never had that conversation with the family until after this event.

Politicians have labelled this merciful conversation as an act of rationing.  That is not only ignorant, it is shameful.  Talking to people about end-of-life issues will certainly save money.  But it\’s a contemptible step to imply that this money is saved by killing the elderly.  It\’s more wrong to make money off of keeping them alive unnecessarily than it is to save money by letting them die when they choose.

This is politics at its ugliest – taking a provision that will reduce suffering and help people and pervert it to be used as a tool to scare the people it will help.  The discussion about healthcare has been subverted by those who want poll numbers.

Shame on you.

50 thoughts on “Dying Patients and Ugly Politics”

  1. I totally agree. I’ve posted on this subject several times before, but I think it wants repeating. All my surviving immediate family have had the conversation about when we want DNR and/or No Heroic Measures directives applied! Also, we’re all tough enough that no Doctor is going to bully us into over-riding them!

  2. I totally agree. I’ve posted on this subject several times before, but I think it wants repeating. All my surviving immediate family have had the conversation about when we want DNR and/or No Heroic Measures directives applied! Also, we’re all tough enough that no Doctor is going to bully us into over-riding them!

  3. I’m unclear why such a conversation is postponed until people are old. Not everyone makes it to old age. If one chooses to wait for such a discussion, whose definition of “old” gets used? (a 10-year old thinks that 25 is old; if your recent ancestors all lived into their 90’s and 100’s, then at age 70 you still anticipate being around for quite a while)
    Why wait to learn a person’s preferences? My husband and I both signed multiple pages of legal gobbledy-gook that supposely boil down to “don’t keep me alive on machines.” Those papers are with our will and other legal papers. We’ve never said anything about it to our doctor, though.

  4. I’m unclear why such a conversation is postponed until people are old. Not everyone makes it to old age. If one chooses to wait for such a discussion, whose definition of “old” gets used? (a 10-year old thinks that 25 is old; if your recent ancestors all lived into their 90’s and 100’s, then at age 70 you still anticipate being around for quite a while)
    Why wait to learn a person’s preferences? My husband and I both signed multiple pages of legal gobbledy-gook that supposely boil down to “don’t keep me alive on machines.” Those papers are with our will and other legal papers. We’ve never said anything about it to our doctor, though.

  5. I’m not talking about DNR in this case. This man was never put on a vent, never shocked, and never had chest compressions done. He was not treated inconsistent with a DNR. The issue is unnecessary care.
    Doctors have a general way we are advised to look at this: look at it in terms of life expectancy. If a person has less than 10-year expectation, then things like colonoscopies and mammograms are not worthwhile. If the expectancy is less than 5 years, using cholesterol drugs is unnecessary.

    This target is obviously changing, depending on the age and health status of the person. So the talk is very much dependent on these factors as to what it contains. I don’t want my wife and kids to be a DNR at this point.

    Why don’t docs talk about this more? First, it is uncomfortable to do so. Second, patients try to read between the lines as to what you are saying about their health. Third, there are a whole lot of other things to be doing and these talks take time. The idea that this kind of conversation would be paid for above and beyond what is already paid is something that will greatly increase the rate at these conversations are happening. That’s a good thing.

  6. I’m not talking about DNR in this case. This man was never put on a vent, never shocked, and never had chest compressions done. He was not treated inconsistent with a DNR. The issue is unnecessary care.
    Doctors have a general way we are advised to look at this: look at it in terms of life expectancy. If a person has less than 10-year expectation, then things like colonoscopies and mammograms are not worthwhile. If the expectancy is less than 5 years, using cholesterol drugs is unnecessary.

    This target is obviously changing, depending on the age and health status of the person. So the talk is very much dependent on these factors as to what it contains. I don’t want my wife and kids to be a DNR at this point.

    Why don’t docs talk about this more? First, it is uncomfortable to do so. Second, patients try to read between the lines as to what you are saying about their health. Third, there are a whole lot of other things to be doing and these talks take time. The idea that this kind of conversation would be paid for above and beyond what is already paid is something that will greatly increase the rate at these conversations are happening. That’s a good thing.

  7. The youngest of the people I was talking about is 44. But that’s not really the point; we didn’t have the conversation when she was a teenager because no-one talked about things like DNRs 25 years ago.I’d agree that everyone who hasn’t had these conversations should have them as soon as children are old enough to understand the issues, and whilst seniors (relative term; early onset Alzheimer’s can affect people in their 50s, and could affect the validity of a DNR) still can.

  8. The youngest of the people I was talking about is 44. But that’s not really the point; we didn’t have the conversation when she was a teenager because no-one talked about things like DNRs 25 years ago.I’d agree that everyone who hasn’t had these conversations should have them as soon as children are old enough to understand the issues, and whilst seniors (relative term; early onset Alzheimer’s can affect people in their 50s, and could affect the validity of a DNR) still can.

  9. Ok, point noted. Your 5:33 didn’t show up here until after my 5:36 for some reason.
    I still agree with you though.

  10. Ok, point noted. Your 5:33 didn’t show up here until after my 5:36 for some reason.
    I still agree with you though.

  11. Good story and amazing perspective on this issue. I agree with all the points you made. Politics is an ugly business. I just do not trust the current leadership and their current tactics (we have a majority and will do whatever we please) to fix healthcare….apparently I’m not alone as i watch the news each evening. So, as ugly as this process is, i don’t mind these tactics (which both sides use too often) to defeat a piece of legislation that is just not going to work. We’ve got to reform our healthcare system and forcing the dems back to square one and encouraging some different ideas in the legislative process is only going to help…..i think?

  12. Good story and amazing perspective on this issue. I agree with all the points you made. Politics is an ugly business. I just do not trust the current leadership and their current tactics (we have a majority and will do whatever we please) to fix healthcare….apparently I’m not alone as i watch the news each evening. So, as ugly as this process is, i don’t mind these tactics (which both sides use too often) to defeat a piece of legislation that is just not going to work. We’ve got to reform our healthcare system and forcing the dems back to square one and encouraging some different ideas in the legislative process is only going to help…..i think?

  13. I can only assume you’re talking about a “doctor-patient” relationship at the end of life moments because you truly do care about your patients. And for that your patients are fortunate people.
    Those of us who oppose the government plan do so because of the “GOVERNMENT part of the mandated government/doctor/patient” relationship. Mandated “discussions” every 5 years at 65 years of age and thereafter, with someone whose concern is NOT ONLY about the patient and family but the dollar cost is too much intrusion.

    I am currently in discussions with my mother-in-law’s doctor about just that – her last years of care. But getting the government involved in these very private matters is inappropriate. I have worked as a hospice nurse and seen unscrupulous health care providers “encourage” people – subtly of course – to change the course of treatment when they needed a bed for someone else. I ask you.. what motivation does our government have BUT to save money???

    Don’t forget, our legislators have yet to agree to participate in the same system they want to foist on us. If you consider that alone.. you need to Re-consider.

    So if we don’t pay attention and don’t make them respond to honest concerns.. then who is to shame?

    Yes, this is ugly, scary and perverted.. Government intervention in our lives generally is like that.

  14. I can only assume you’re talking about a “doctor-patient” relationship at the end of life moments because you truly do care about your patients. And for that your patients are fortunate people.
    Those of us who oppose the government plan do so because of the “GOVERNMENT part of the mandated government/doctor/patient” relationship. Mandated “discussions” every 5 years at 65 years of age and thereafter, with someone whose concern is NOT ONLY about the patient and family but the dollar cost is too much intrusion.

    I am currently in discussions with my mother-in-law’s doctor about just that – her last years of care. But getting the government involved in these very private matters is inappropriate. I have worked as a hospice nurse and seen unscrupulous health care providers “encourage” people – subtly of course – to change the course of treatment when they needed a bed for someone else. I ask you.. what motivation does our government have BUT to save money???

    Don’t forget, our legislators have yet to agree to participate in the same system they want to foist on us. If you consider that alone.. you need to Re-consider.

    So if we don’t pay attention and don’t make them respond to honest concerns.. then who is to shame?

    Yes, this is ugly, scary and perverted.. Government intervention in our lives generally is like that.

  15. Object to the things you disagree with. I am fine with that. But hijacking something that truly has merit and using it to scare people is shameful. The goal is to fix healthcare, not to win political battles. Everything I have read in this part of the legislation is reasonable, but perhaps I don’t see it things that are there. My suspicion, however, is that people are reading intent into this – meaning that they feel like they know the agenda of the administration and so read all things they do through that light. If you believe that they want to ration care and cut off care for the elderly, this will seem ominous. I don’t see it there. I think people are reading in this something that isn’t there.

  16. Object to the things you disagree with. I am fine with that. But hijacking something that truly has merit and using it to scare people is shameful. The goal is to fix healthcare, not to win political battles. Everything I have read in this part of the legislation is reasonable, but perhaps I don’t see it things that are there. My suspicion, however, is that people are reading intent into this – meaning that they feel like they know the agenda of the administration and so read all things they do through that light. If you believe that they want to ration care and cut off care for the elderly, this will seem ominous. I don’t see it there. I think people are reading in this something that isn’t there.

  17. Where is the “mandate?” It seems to me like they are saying that they will reimburse for this. Yea! I get paid for doing good instead of just doing more procedures. We need to encourage these discussions because there is no other source of natural resistance to the practice of maximizing the revenue we can squeeze out of each patient. When the person goes to the hospital, the hospital and the doctors who work in it are rewarded for doing more. They often resist the temptation, but in this case someone dropped the ball. Why not instead reimburse my discussion with patients about not doing as much?

  18. Where is the “mandate?” It seems to me like they are saying that they will reimburse for this. Yea! I get paid for doing good instead of just doing more procedures. We need to encourage these discussions because there is no other source of natural resistance to the practice of maximizing the revenue we can squeeze out of each patient. When the person goes to the hospital, the hospital and the doctors who work in it are rewarded for doing more. They often resist the temptation, but in this case someone dropped the ball. Why not instead reimburse my discussion with patients about not doing as much?

  19. I agree.There is no mandate in the bill that I read, and it does not say the government is involved. It simply says that “Advance Care Planning Consultation” will be reimbursed provided the ” individual involved has not had such a consultation within the last 5 years.” It is not mandated every 5 years.

  20. I agree.There is no mandate in the bill that I read, and it does not say the government is involved. It simply says that “Advance Care Planning Consultation” will be reimbursed provided the ” individual involved has not had such a consultation within the last 5 years.” It is not mandated every 5 years.

  21. I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don’t like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.

  22. I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don’t like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.

  23. I do take offense to having my elderly alzheimer patient used as a glove in a political slapping contest. The government is not mandating, they are just saying that they will pay for it to get done every 5 years. What’s wrong with that? I like to get paid to do a job. I especially like to be paid for a job that makes peoples’ lives better (as opposed to those folks in the hospital who got paid for putting this patient through the mill for no gain).
    If you read the bill, it does not say anything about the government being involved in the process of end-of-life decisions except that they would financially support the discussions? Is it the “slippery slope” that makes everyone break out in hives from this? I just don’t understand. I certainly don’t think the government should be stepping in and saying people should die. As the system is right now, the government (through Medicare) is rewarding doctors to ignore the suffering of these patients and do lots of tests and procedures on them. The government is already involved!! Call this a correction of course. Just don’t use my patients as pawns in politics.

  24. I do take offense to having my elderly alzheimer patient used as a glove in a political slapping contest. The government is not mandating, they are just saying that they will pay for it to get done every 5 years. What’s wrong with that? I like to get paid to do a job. I especially like to be paid for a job that makes peoples’ lives better (as opposed to those folks in the hospital who got paid for putting this patient through the mill for no gain).
    If you read the bill, it does not say anything about the government being involved in the process of end-of-life decisions except that they would financially support the discussions? Is it the “slippery slope” that makes everyone break out in hives from this? I just don’t understand. I certainly don’t think the government should be stepping in and saying people should die. As the system is right now, the government (through Medicare) is rewarding doctors to ignore the suffering of these patients and do lots of tests and procedures on them. The government is already involved!! Call this a correction of course. Just don’t use my patients as pawns in politics.

  25. And I should have mentioned, my husband and I are in our 40s and have had living wills set up for five or six years now. Everyone, not just the elderly, needs to talk to their loved ones and then put in writing (or vice versa) what they want if/when calamity or serious illness happens. It’s fine if people WANT everything done to try to save and extend their lives, but most of us don’t want to be hooked up to a ventilator and left there if we’re brain dead and there’s no chance of recovery. If I get cancer, I certainly will try to fight it, but if I’m losing the battle, at some point, I’m going to want to go on hospice and concentrate on quality of life and not quantity. It’s only right that Medicare (and other insurance plans) should pay for an occasional doctor visit to discuss one’s wishes and make sure both the patient AND the doctor understand what the plan is.

  26. And I should have mentioned, my husband and I are in our 40s and have had living wills set up for five or six years now. Everyone, not just the elderly, needs to talk to their loved ones and then put in writing (or vice versa) what they want if/when calamity or serious illness happens. It’s fine if people WANT everything done to try to save and extend their lives, but most of us don’t want to be hooked up to a ventilator and left there if we’re brain dead and there’s no chance of recovery. If I get cancer, I certainly will try to fight it, but if I’m losing the battle, at some point, I’m going to want to go on hospice and concentrate on quality of life and not quantity. It’s only right that Medicare (and other insurance plans) should pay for an occasional doctor visit to discuss one’s wishes and make sure both the patient AND the doctor understand what the plan is.

  27. I am reminded of my mother’s situation…she was sitting enjoying a cigarette one minute, comatose the next. The diagnosis was subarachnoid hemorrhage, and by the time the hospital found family (me) to make decisions on her behalf (we were estranged and I hadn’t seen or heard from her in over 10 years) she’d survived overnight despite her very bad odds.
    Her attending physician was OUTSTANDING. He told me straight what to expect and together we talked about what should and shouldn’t be done. I spoke to the nurse who documented the decisions, and made plans to travel to Connecticut to spend time with the prodigal mother who wouldn’t know I was there.

    Within hours, a very angry neurosurgeon was on the phone, shouting at me and berating me for not giving my mother the ‘best chances possible.’ I was completely defeated, but only because of the guilt of our personal family dynamic, which is too convoluted to describe. I assented, and the neurosurgeon took her into surgery.

    Not too long after that, I got another call from her attending. He was upset, too. I cried as I explained what had happened: I was a thousand miles away and making decisions on behalf of someone who had spit in my face and told me I was going to hell the last time I saw her, and I was only doing the best I could. After hearing me out, this doctor said “as long as you do the best thing for her, you’re doing all you should do. We just have to decide what the best thing is, and stay on that path.” From that moment on, he carefully monitored her “traffic” and I got daily updates when I wasn’t in the hospital with her. No other treatment-happy doctors called with threats or dire predictions.

    Despite predictions, she survived almost 90 days after the hemorrhage. She was given some therapy, kept fed and clean and comfortable. She was even weaned off the respirator and breathing on her own for a few weeks before she died. She was treated with dignity, her needs provided for, and nothing more. It’s what I would have wanted for myself.

    The best thing to come from the situation was the family discussion about what we each wanted in the event one of us wound up in the same situation. Our family had its own ‘death panel’ while we were all in good health and no one was emotional about it. I am very clear on what to do for my father and sister.

  28. I am reminded of my mother’s situation…she was sitting enjoying a cigarette one minute, comatose the next. The diagnosis was subarachnoid hemorrhage, and by the time the hospital found family (me) to make decisions on her behalf (we were estranged and I hadn’t seen or heard from her in over 10 years) she’d survived overnight despite her very bad odds.
    Her attending physician was OUTSTANDING. He told me straight what to expect and together we talked about what should and shouldn’t be done. I spoke to the nurse who documented the decisions, and made plans to travel to Connecticut to spend time with the prodigal mother who wouldn’t know I was there.

    Within hours, a very angry neurosurgeon was on the phone, shouting at me and berating me for not giving my mother the ‘best chances possible.’ I was completely defeated, but only because of the guilt of our personal family dynamic, which is too convoluted to describe. I assented, and the neurosurgeon took her into surgery.

    Not too long after that, I got another call from her attending. He was upset, too. I cried as I explained what had happened: I was a thousand miles away and making decisions on behalf of someone who had spit in my face and told me I was going to hell the last time I saw her, and I was only doing the best I could. After hearing me out, this doctor said “as long as you do the best thing for her, you’re doing all you should do. We just have to decide what the best thing is, and stay on that path.” From that moment on, he carefully monitored her “traffic” and I got daily updates when I wasn’t in the hospital with her. No other treatment-happy doctors called with threats or dire predictions.

    Despite predictions, she survived almost 90 days after the hemorrhage. She was given some therapy, kept fed and clean and comfortable. She was even weaned off the respirator and breathing on her own for a few weeks before she died. She was treated with dignity, her needs provided for, and nothing more. It’s what I would have wanted for myself.

    The best thing to come from the situation was the family discussion about what we each wanted in the event one of us wound up in the same situation. Our family had its own ‘death panel’ while we were all in good health and no one was emotional about it. I am very clear on what to do for my father and sister.

  29. Powerful stuff, Jean. Hard to believe that neurosurgeon did what he did. It’s downright maddening to hear it.

  30. Powerful stuff, Jean. Hard to believe that neurosurgeon did what he did. It’s downright maddening to hear it.

  31. I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don't like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.; I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don't like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.;;

  32. I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don't like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.; I agree that one should have end of life discussions. I am 67 and my mother is 88, my children and my mother have all had these discussions. What I don't like is the government involvement. Do I not trust them? Absolutely!!! When Bush wanted to reform social security and Newt talked about reforming Medicare all we heard was Bush wanted to throw gramdma out in the street and Newt wanted to kill the elderly. Payback is a bitch. The great community organizer is getting a little organizing.;;

  33. I thought that, Jennifer, but I was afraid to point the finger too harshly. the neurosurgeon had very mixed-motives at best. Having the craniotomy cancelled would have cost him a lot of money. It’s hard to believe this isn’t factored into his decision. That’s why I have such a beef with people not wanting me to be paid to try and prevent this sort of thing.
    Perhaps this is a microcosm of the entire problem. Jean’s mom cost another $40,000 and Jean had agreed to do nothing. Nobody took away her right to get the surgery done on her mom, but the system slants heavily away from the patient and the family and toward spending lots of money. We can’t keep doing this kind of thing.

  34. I thought that, Jennifer, but I was afraid to point the finger too harshly. the neurosurgeon had very mixed-motives at best. Having the craniotomy cancelled would have cost him a lot of money. It’s hard to believe this isn’t factored into his decision. That’s why I have such a beef with people not wanting me to be paid to try and prevent this sort of thing.
    Perhaps this is a microcosm of the entire problem. Jean’s mom cost another $40,000 and Jean had agreed to do nothing. Nobody took away her right to get the surgery done on her mom, but the system slants heavily away from the patient and the family and toward spending lots of money. We can’t keep doing this kind of thing.

  35. What a fantastic blog entry! The frustration you felt with your Alzheimer’s patient is something most of us in health care can whole-heartedly empathize with. We have all had experiences where we ask ourselves “WHY?” when we find out that an elderly or terminal patient enters a critical care area through an emergency room with no discussion of “wishes”. If they fall into the hands of an aggressive team, they can be sucked into an endless barrage of tests, exams, procedures, vital signs, bloodwork, and sometimes (read that as ‘most times’) unnecessary pain & suffering. Why intubate an obtunded ninety-four year old end-stage COPDer with chronic renal failure on hemodialysis? Why take a 96-year insulin-dependent diabetic woman with an EF of 20% to the cath lab just because she has chest pain? Working in an ICU, many of these scenarios actualize in my daily patient care. I could just cry. Much of my nursing care is spent talking to family members, trying to make them realize that they have a say in the health care choices & the plan! Most people feel helpless and don’t speak up on behalf of their elderly or terminally ill family members. Some patients have no family to speak for them! They have the potential to suffer needlessly unless the hospital staff rebels. Sometimes we need to involve hospital ethics committees when we feel that care should be re-evaluated for appropriateness at end-of-life.Again, great great topic. I could go on forever about this issue, so I best stop right now.
    I will end this comment by quoting something you wrote in your blog. Very poignant, so simple to perceive, yet at times so hard to follow~

    “There is a point when the focus shifts from quantity of life to quality of life. There is a time after which a death is no longer tragic, but instead the end of a story. “

    Thanks, Dr. Rob! Loved the post! 🙂

    Ellen
    http://twitter.com/EllenRichter

  36. What a fantastic blog entry! The frustration you felt with your Alzheimer’s patient is something most of us in health care can whole-heartedly empathize with. We have all had experiences where we ask ourselves “WHY?” when we find out that an elderly or terminal patient enters a critical care area through an emergency room with no discussion of “wishes”. If they fall into the hands of an aggressive team, they can be sucked into an endless barrage of tests, exams, procedures, vital signs, bloodwork, and sometimes (read that as ‘most times’) unnecessary pain & suffering. Why intubate an obtunded ninety-four year old end-stage COPDer with chronic renal failure on hemodialysis? Why take a 96-year insulin-dependent diabetic woman with an EF of 20% to the cath lab just because she has chest pain? Working in an ICU, many of these scenarios actualize in my daily patient care. I could just cry. Much of my nursing care is spent talking to family members, trying to make them realize that they have a say in the health care choices & the plan! Most people feel helpless and don’t speak up on behalf of their elderly or terminally ill family members. Some patients have no family to speak for them! They have the potential to suffer needlessly unless the hospital staff rebels. Sometimes we need to involve hospital ethics committees when we feel that care should be re-evaluated for appropriateness at end-of-life.Again, great great topic. I could go on forever about this issue, so I best stop right now.
    I will end this comment by quoting something you wrote in your blog. Very poignant, so simple to perceive, yet at times so hard to follow~

    “There is a point when the focus shifts from quantity of life to quality of life. There is a time after which a death is no longer tragic, but instead the end of a story. “

    Thanks, Dr. Rob! Loved the post! 🙂

    Ellen
    http://twitter.com/EllenRichter

  37. I’ve no idea what that surgery cost, but just her hospital bill from late January to March 17, 1992 was a tad over $360,000.
    BTW, my mother was living in a homeless shelter when the hemorrhage occurred. The hospital and the doctor didn’t know she had BCBS of Alabama until after I spoke to her physician and the nurse…maybe *that* is why the neuro was suddenly in a big hurry to operate?

    I have no problems ascribing his call to greed. He certainly didn’t have my mother’s best interests at heart.

  38. I’ve no idea what that surgery cost, but just her hospital bill from late January to March 17, 1992 was a tad over $360,000.
    BTW, my mother was living in a homeless shelter when the hemorrhage occurred. The hospital and the doctor didn’t know she had BCBS of Alabama until after I spoke to her physician and the nurse…maybe *that* is why the neuro was suddenly in a big hurry to operate?

    I have no problems ascribing his call to greed. He certainly didn’t have my mother’s best interests at heart.

  39. This was a really thought-provoking post — I’m the youngest in my family, and I’ve never felt like I had to take responsibility for my parents’ old age — but who does? It seems like every second that people can be provoked into sitting down and thinking about the ends of their lives, even though it’s unpleasant, is a priceless second and one that can prevent so much suffering and confusion.

  40. This was a really thought-provoking post — I’m the youngest in my family, and I’ve never felt like I had to take responsibility for my parents’ old age — but who does? It seems like every second that people can be provoked into sitting down and thinking about the ends of their lives, even though it’s unpleasant, is a priceless second and one that can prevent so much suffering and confusion.

  41. My family went through this last fall when my 93 year old demented grandmother fell and broke her hip at the assisted living facility. The orthopod told my sister that my grandmother would be up and walking around again after a total hip, so she agreed to the surgery. (she wasn’t doing much walking or functioning). I called and suggested they needed to do “comfort care.” My sis and relatives did not know what to ask for. She was transferred to hospice where she got outstanding end of life care and died 3 weeks later. We all paid for that bad advice and my grandmother suffered greatly in that hospital admission/total hip surgery (they said she didn’t need pain medication after surgery). Heck, my cat got pain medication after his sterilization and my grandmother didn’t need pain meds after a hip replacement???

  42. My family went through this last fall when my 93 year old demented grandmother fell and broke her hip at the assisted living facility. The orthopod told my sister that my grandmother would be up and walking around again after a total hip, so she agreed to the surgery. (she wasn’t doing much walking or functioning). I called and suggested they needed to do “comfort care.” My sis and relatives did not know what to ask for. She was transferred to hospice where she got outstanding end of life care and died 3 weeks later. We all paid for that bad advice and my grandmother suffered greatly in that hospital admission/total hip surgery (they said she didn’t need pain medication after surgery). Heck, my cat got pain medication after his sterilization and my grandmother didn’t need pain meds after a hip replacement???

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