I was recently reading an article written by a guy who said he wanted to die at 75 years old.
I thought for sure I was going to disagree with every bit of the article. There were definitely parts that I didn't agree with, such as foregoing some basic cancer screening. (I think I would do anything to keep from dying of colon cancer.) I don't agree with the basic philosophy, that once you slow down significantly, life is not worth living. Plenty of people over 75 have wonderful and worthwhile lives, even if they can't do with they could do when they were 30.
That said, with the aging population, I do think medical treatment to people over 75 (to set an arbitrary cut off) should be limited.
I do think the elderly should have access to antibiotics, flu shots, and medications, and should see physicians frequently. But nobody in their 80s should be allowed to be full code. It just doesn't make any sense in terms of expected recovery. Furthermore, I think cancer treatment should be palliative only at that point. Any major surgeries, such as a bypass surgery, should be avoided. Nobody over that age should be allowed to have a trach or feeding tube. The chances of recovering and having a reasonable quality of life after these interventions is just not high enough to justify it. Frankly, I think it's just cruel to the patients, in addition to being a waste of medical resources.
The most important thing is that the decision ought to be taken out of the hands of the patient or family members. It feels so ridiculous when we ask a 90-year-old if they want to be full code. A lot of the time, the patient or family will say yes, because they just don't understand what it means. They think not being full code means we won't treat their family member, but what it really likely means is it their family member will not have to die on a ventilator. Or alternately, they do understand what it means, but feel guilty making any other decision. I am still angry with my mother for putting my grandmother through a "life prolonging" surgery instead of withdrawing care when the doctor essentially told her there was no chance of recovery, but she said she felt guilty doing anything else.
For starters, I think everybody over the age of 80 should automatically be DNR. And we should seriously consider what other medical interventions should be offered to people who most likely won't benefit from it.
Ready, set, go... here come the angry comments. But, I agree completely.
ReplyDeleteMaybe I am foolish, but I believe my readers are mature enough to debate this without losing their tempers.
DeleteThis is an "anti-choice" position
ReplyDeleteI agree with you completely. Kinda funny how people call themselves pro-choice when there are a lot of choices they don't want to uphold.. not that that is an unreasonable position to have, just that we ought to do away with labels and call the position what it really is rather than using fluffy terms. (This isn't directed at you personally, Fizzy.)
DeleteI respect the right to refuse treatment, but if someone wants heroic measures and they can pay for it, then that's their choice to make. (granted, the money issue is huge)
It's up to them, really. What "quality of life" and "dying with dignity" means to one person isn't the same as what it means to another.
Every choice is not available to every person though. I couldn't go out and punch somebody in the face if I wanted. I couldn't go live in a Beverly Hills mansion if I wanted to. So I don't think it's entirely reasonable that a person should not be allowed to have a treatment that is very expensive and essentially futile.
DeleteYes, if someone wants to pay out-of-pocket for these treatments, fine. But nobody actually would. And if the insurance companies are paying for treatments that are essentially futile, it hurts everybody else. including the patient receiving the treatment, because these funds would probably be better redirected towards services like improving nursing homes, home nursing services, or home hospice. I work almost exclusively with elderly people and the thought of death scares them much less than the thought of going to a horrible nursing home or prolonged hospitalization or being on a ventilator.
Therese wrote: "if someone wants heroic measures and they can pay for it, then that's their choice to make."
DeleteThe problem with this logic is that no one pays out of pocket. "So what? I have insurance," you say? Insurance companies pay hundreds of thousands of dollars for the end-of-life care of too many folks who never had a real chance of survival. This is one reason for ever-rising insurance premiums.
And when Medicare pays, taxpayers foot the bill. I'm not willing to do that for folks who really have no chance of survival simply because they feel entitled to make a choice. No one is entitled to health care that lacks a reasonable chance of providing either enhanced quality of life or significant out-of-hospital survival benefit (so a treatment that gives one an extra week of hospitalized life is not worth $100k).
People who have zero (yes, ZERO!) chance of survival often ask us to "do everything" because they think of surviving a lot like winning the lottery. Survival occurs only rarely by sheer luck.
When my time comes I plan to walk this talk -- not mainly for financial reasons but because life-prolonging care causes incredible suffering. I want to die quickly, and if that doesn't happen, I'll be grateful if I can access palliative care to treat my pain until I die.
I couldn't have said it any better, pgyx.
DeleteI would have agreed with you completely, but then my 70 something-year-old father blew everybody's expectations away by responding and recovering very very well for me Whipple procedure that nobody wanted him to undergo, but he insisted on having. It's cases like his that make me feel like blanket assumptions can't be made.
ReplyDeleteMaybe. But how many dozens of people had a horrible recoveries and remain sick and never left the hospital after that sort of procedure at his age? The overwhelming odds are of not recovering.
DeleteHe's definitely in the minority, that's for sure. But the point is a one-size-fits-all approach to these types of large social issues doesn't really work. I have also been thinking, since his illness, is it fair for me to tell him how to live his life when I'm not at that age and as close to mortality is he is? Maybe my mind will change as I get older, maybe I will want to live a bit longer despite facing serious illness. It's kind of hard to know how you really feel until you are in those shoes. Even physicians sometimes make difficult decisions to except harsh treatments to prolong their own lives. Not all of them take the more pragmatic approach of refusing chemo and radiation simply because they know the odds of meaningful recovery are slim.
DeleteI think one key argument is that health resources are not infinite. The aging population is growing. If people who are in their 80s are getting chemo and radiation, The resources available to young people who actually have a very good chance of recovery will be smaller. Does that seem reasonable?
DeleteIt's a valid counter argument. I certainly wouldn't disagree with that. But I'm sure my father's argument would be that he's already paid into the system to receive the treatments that he's received.
DeleteI think a much better use of resources for the elderly, is providing good assisted-living places and home nursing care to keep elderly people out of nursing homes as long as possible. If I were 80, I'd rather have that resource than some risky cancer treatment that would likely be painful and probably not prolong my life.
DeleteFair enough, as long as you also recognize that, in order to give people quality nursing home/hospice care, we need to spend a shitload more money than we currently do. My grandmother is in nursing care and let me tell you, it's total crap to the point of being inhumane, and if I could afford to move or elsewhere, I totally would.
DeletePaying for a Whipple procedure for an elderly person then subsequent months of care, chemotherapy and radiation has got to be cheaper than having a nurse come in once or twice a day to help a patient with their medications. Allowing the patient to stay in their home is cheaper than providing a bed in a nursing home. The allocation of medical resources makes no sense to me.
DeleteI completely agree that nursing homes are terrible, but I think it would help just as much to keep people out of them. We send so many people to nursing homes who wouldn't need to be there if we could get them just a few more services for home. And then the nursing homes would be less crowded and maybe it would be easier to get better care.
DeleteI'm a ICU RN and have to agree with you 100% I see patients daily that we are essentially forcing to be 'alive' but not allowing to live. If there were accepted guidelines I think the Healthcare system would be much less burdened and people could end their lives in a much more dignified manner.
ReplyDeleteExactly. I am certain that most people would prefer to die in their own home in a dignified manner than what actually ends up happening to many people.
DeleteIf the family of a 90+ year old got to see a videotape of an actual full code, with rib-fracturing surround sound, they may think twice before putting their loved ones through that kind of trauma.
ReplyDeleteThat's the problems right there. Lack of education. The average person has no idea and the idiots out there who labeled this part of Obamacare a "death panel" can go you-know-where.
DeleteRight. Education would go a really long way. I doubt anyone would want to extend their life by six months if those six months are likely to be spent in the ICU on a ventilator.
DeleteI have to agree with you. Ask most people and they would say they'd like to die after the age of 80, suddenly, in their own home, never be in the hospital or a nursing home or needing full care. Yet, because of lack of understanding or communication, these same people & their families will go full code, or push for the chemotherapy or other life-sustaining treatment.
ReplyDeleteThe recent article by Atul Gawande in the New Yorker was eye-opening in terms of how oncologists give false hope to terminal cancer patients about unproven and unlikely to work therapies. I'm sure this is not limited to oncologists, most doctors, being human, are uncomfortable telling someone they are going to die and should not try any treatments to prevent it. There needs to be big shift in how people think about death in this country before anything changes---education to doctors and patients, that begins well before the terminal diagnosis is given.
I do mostly agree. Although I think it is probably inhumane not to try to fix a broken hip in someone otherwise healthy, and I have a cousin who had skin cancers removed in his 90s and is now 100 and still living a good life in his own home, including a recent 300 mile-away holiday to see relatives. So I would offer the non-demented over 80s (I'd put it at 80) the "one-off quick cures" but hold off on the big interventions and long courses of treatment with uncertain outcomes.
ReplyDeleteDementia or the lack of it makes a big difference, I suspect.
Becomes a pretty slippery slope, though, once you start exercising judgment as to who can get what treatment. This is the biggest problem with the concept being proposed.
DeleteThe decisions are already being made by insurance companies though, which are the last people you want to be making these kinds of decisions. If providing a futile treatment for an elderly person means that younger people can't get access to lifesaving treatment, there's something very wrong. or if we can give an elderly person chemotherapy, but we can't get a nurse's aide to come in to help them with their medications so they don't have to go to a nursing home, that's also a problem.
DeleteI would say fixing a broken bone should count as a palliative treatment. And yes, dementia should be a contraindication to a serious surgery, because those particular patients tend to do poorly and probably will never regain any sort of reasonable quality of life.
I don't agree, though only because a blanket age limit is arbitrary and unjustified. While age should be considered as a "comorbidity" that should guide our decision-making, there is a lot of variation in frailty amongst the 75+. I also wonder how much your view is coloured by your job - you are, after all, seeing a lot of the patients who have had the kinds of prolonged, incomplete recoveries after interventions rather than the well ambulatory patients who had their elective hip done at 79.
ReplyDeleteAlong the same lines, avoidance of codes makes sense in most cases, but not always. Similarly, for the 79 yo with critical aortic stenosis, do you simply palliate their impending failure and dyspnea, or do you send them for a tissue AVR or even a TAVI?
On the other hand, I agree that chemo is generally not appropriate for the elderly, but certainly palliative radiation can be pretty reasonable.
I also reject any argument from the standpoint of scarce resources. They simply aren't scarce in rich countries, not to the extent that it should matter greatly.
Actually, I see tons of healthy hip replacement patients and I agree with you that it is not so black-and-white. I guess the things that I feel most strongly about are the code status and the aggressive cancer treatments. I think intubating someone in their 80s for anything other than a surgery is a mistake. Other things are more debatable.
DeleteI have code status discussions all the time. Most of the time, people are quite agreeable to whatever I recommend (which, if I'm bringing it up, amounts to "you or your loved one is unlikely to benefit from this") once they understand that "DNR" does not mean "Do nothing".
DeleteThese days we have more options short of intubation for management of milder respiratory failure. BiPAP and Optiflow are great for that. The other part of this is that intubating a 70 yo with severe COPD is an excellent way of ensuring they get trached.
One final issue comes up when a 90 yo from a nursing home falls, breaks her hip, and needs it nailed, despite - let's say - "mild" dementia. It's challenging since the acute issue, if left alone, will definitely kill her, but the OR has risks of its own, albeit ones that are less than not doing anything.
Either way, it's all about good decision-making in the moment where we consider the net benefit. A few months ago I was on call on a community elective and my staff and I were asked to see an evidently demented lady who'd given herself a compound wrist fracture. She was singing in emerg and not altogether cooperative with IV placement of bloodwork. We thought that putting her out would be an ordeal, but in the end managed with a bit of propofol, an LMA, and a single dose of Toradol while the surgeon did a simple closed reduction. And she was singing again in recovery.
So, things can work out - but it's a matter of ensuring that we recognize that dementia, especially, is a major comorbidity, even if it's not necessarily a reason not to undertake any intervention .
I agree with the content of your suggestion … But I can't imagine how to execute it (so to speak) without seeming a lot more like a death panel than like the end of life discussions that were later termed 'death panels.' I think the only way to achieve what you are saying is not to mandate it but to slowly a) educate the public more about what heroic measures look like and what they achieve AND b) change the culture of death and dying. Articles and books like what Gawande has written are the kind of thing that can achieve both a) and b). I also think doctors like oncologists naturally overplay the possible success of their treatments because they are so invested in them. I don't think they are trying to be harmful. I am sure they want to offer hope and their patients want hope. Those two forces can be destructive in the end. Just like patients receive mandated information about the risks of a procedure - the risks of other treatments should be given in a more objective fashion with a very clear understanding of chances for "success" and a definition of what that means. (Does it mean an average of 2 more months, but a total of 6 months with a terrible drug, for example?) Patients should absolutely also be told the truth. For most advanced cancers, palliative care actually EXTENDS life more so than lifesaving treatment! This is a well-established fact that is little known in the general public and even among many health professionals. (Again, this is specifically for advanced cancers, of course).
ReplyDeleteI agree with you completely! I am a physician and work in an Emergency Dept and ICU, and I can honestly say that so much of the care we provide to elderly patients is futile. Educating the public about this futility has only limited benefits, as people who are not in the medical field just don't understand - it's not even a question of intelligence, it's just a question of understanding something when you've lived inside it rather than from the outside. Therefore, the decision should be taken out of their hands at some point. Also, non-medical people tend to equate these discussions with euthanasia, or that, in making these decisions for patients, we as physicians are making value judgements on someone's life and whether or not it's "worth the expense", when, in reality, it's a matter of the futility of the care. It's not that I don't think the bed bound 90 y.o nursing home patient with end-stage everything's life is of no value, it's that I think any kind of aggressive medical intervention would be of absolutely no discernible benefit.
ReplyDeleteI agree and yet I also hate the thought of some stranger mandating what I must do.
ReplyDeleteI also think you could add another rule, if there is any sign whatsoever of dementia, at any age, then no care other than comfort care. No pacemakers, etc. If the mind is gone, we should not save the body.
Dang, it sounds so harsh, yet I would never want those interventions you outlined for me or my family at that advanced age.
My feelings about not doing surgery or other interventions on people with dementia is more about the fact that they tend to do particularly poorly. I've had so many patients who are mildly demented then went in for a major surgery and came out completely off-the-wall confused. And never recovered.
DeleteThe important thing is that real statistics and not feelings need to be used to make these rules. I think if people had any clue what the statistics are about resuscitation on elderly people nobody would ever be full code after a certain age. But I think even people who are presented with the statistics don't truly understand them. In the case of my grandmother, probably tens of thousands of dollars worth of procedures were done to keep her in a coma for several months and never regain consciousness, which the doctor told my mother was the inevitable outcome.
Couldn't this be solved with education? Instead of saying, do you want me to code, could you say "do you want me to do chest compressions that will break your ribs, insert tubes on your throat...?" When the facts are presented, most people will make reasonable decisions. I just went through this with my grandfather. I had to fight a medical establishment to prevent a pacemaker in a 91 y.o. With heart failure, kidney failure and milks dementia. The doctors and nurses acted like I was the crazy one. I got him to his home with Hospice and he died with his wife of 60 years at his side. But I wasn't someone who pushed and questioned, he could still be lingering somewhere.
ReplyDeleteWe do provide education. It doesn't convince everyone. Family love and guilt can powerfully overwhelm any reasoning. Even after hearing in simple terms that certain interventions will be intensely painful and will not prolong a patient's life, many families still insist upon the interventions.
DeleteWe violate the oath to do no harm every time we have to act to one of these misguided families or patients.
I made life easy. I took the control out of everyone and said let me die in writing, with the lawyer.
ReplyDeleteMake sure you tell everyone in your life of your wishes AND keep something in your wallet to that effect. Can't count the number of times we've done CPR on a person who we later learned had a living will with DNR wishes.
DeleteI agree. Some institutions show video of codes/people on feeding tubes and ventilators to patients and families during the code/care discussion. Makes for a lot more informed decision making. It ain't like they show it on TV, folks. And for the record, my 82 year old mother who has two diseased heart valves she is NOT having fixed (thankyouverymuch) agrees with you too.
ReplyDeleteWhile I don't disagree, some things should be personalized. My grandmother's sister had a heart valve substituted at 83. She lived some very happy 16 years before she died at 99, and she enjoyed every minute of them. But then again, she was one in a thousand. I wouldn't have wanted that new valve for my own grandmother, but her situation was so different from her sister's.
DeleteI agree with you 100%, but why don't we have serious code discussions with patients and their families of people who are 40-60 y.o. with terminal diseases? I feel like sometimes we determine code status on age and we don't look at the patient and their overall prognosis. An 80 year old with no major co-morbidities may a better chance of surviving a code than a 40 year old with CA w/ mets.
ReplyDeleteSorry, but no matter how "misguided" you think the decisions of the individual and their families may be, I staunchly believe that medical/end of life decisions should be theirs and theirs alone. While doctors have a wealth of knowledge, they are not all-seeing. The decisions should be made by individuals and their families.
ReplyDeleteDoctors are not all-seeing, but there are certain clinical presentations that will virtually never result in anything but death or permanent coma/vegetative state. In those cases we may prolong life for a period of time, but we will not prevent the inevitable nor achieve quality of life gains.
DeleteI cannot count the many families who asked for "everything" and later tearfully regretted their choice after they saw the extra suffering their decisions caused in their loved ones. Their hope caused a certain blindness at the time. So while doctors are not all-seeing, we have accompanied countless patients during their hospital-based end-of-life struggles and would prefer not to cause further needless suffering.
If people want medical care that will fail to provide benefit then they and/or their families are technically welcome to pay for it. But why isn't it an ethical violation for doctors and nurses to provide this type of care? If the situation were reversed and doctors actually recommended these same futile treatments, we could reasonably face malpractice and/or fraud charges. Why are families permitted to make these choices based on little more than hope?
The QALY has been developed to determine the cost-effectiveness of medical treatment, but perhaps there is a case for developing a scale which instead of setting the price of treatment against the length and quality of life gained sets out the stress, pain and deleterious effects of treatment against the length and quality of life gained.
ReplyDeleteI am 75. My health is "fragile" with multiple issues. I have a "living will" that states I do not want any "heroic" measures, including no dialysis even short term. I have had an good life, and all my children and spouse are aware of my feelings on this subject. Let me go when my times comes, no matter how difficult the decision may be. As long as I have my mind (which is sharp and good), and I can continue to live independently, then I don't mind longevity. But not at any price! I agree that we need more education for the general public on this topic - I worked in a hospital for 10 1/2 years and am interested in the medical field, but most people I come in contact with are not educated in this area. I had friends tell me that you should never put anyone in hospice because "they kill people." I was at a loss as to how to respond to that...
ReplyDeleteWith as many postCPR situations (months and years afterwards) I have seen in the hospital (young or middle aged, yes), I want to be a "No CPR" too. And I am 24.
ReplyDeleteHaving your heart beat doesn't mean having your brain work.