Dying of old age in the era of modern medicine

He is 93 and has numerous medical problems, most of which involved aging blood vessels, as well as multiple orthopedic issues, including compression fractures and diffuse arthritis. The bony issues have resulted in a severely compromised mobility of late.

Despite ongoing treatment with both aspirin and clopidogrel, he presents after numerous hours of focal neurologic symptoms. A CT scan shows no evidence of bleeding and the diagnosis is a major stroke in a 93-year old who is already taking two anti-platelet medicines. The issue is what to do next?

Reportedly, a rhythm strip somewhere shows atrial fibrillation and so heparin is given in addition to the two other blood thinning drugs. It was clear that this case was destined to end poorly — “rock and a hard place” comes to mind.

The next day brought a worsening of mental status and another CT scan showed bleeding in the brain. Soon, he drifted off into an unrelenting sleep, and passed away that same day.

Much discussion centered around the question of adding a third blood thinner in a 93-year old with a stroke. The discussion was detailed and rigorous, and studies were cited. Important tenets of acute stroke care were learned and a medical education continued. However, what struck my brain more than the medical details was a distant childhood memory.

I was a little boy, and the memories have much fog and a face is barely seen. He was my great grandfather who lived with my grandparents in the home next to mine. Four generations lived within a baseball throw. He was very old and grumpy and always sat in the same chair next to the Frigidaire. Little else is recalled except the coffee can under his saggy bed upstairs. My grandmother, Nellie, emptied it each morning and now after many years of observing the elderly, I understand the difficulties in nocturnal ambulation to the only downstairs bathroom when in your ninth decade of life.

One day after school a commotion happened next door and soon an ambulance came. “Naunoo,” as he was known to the children had a stroke and died very soon in the hospital.

I was told he died of “old age.” Before the era of anti-platelet drugs, CT scans, MRI and angiography one could die of old age.

In modern day medicine, since there is so much to see on scans and many tools to treat, we often forget that humans are mortal and the body eventually loses. The CT scan revealed bleeding in the brain, but the inciting event was a large stroke in a very old man, who likely was destined to live in a nursing home for the remainder of his life had he not passed.

With so many trees sometimes the forest is difficult to see.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • http://www.bryantsstatisticalconsulting.com Tex Bryant

    When to use hospice is a good question. In my volunteer work with my local hospice I have seen that the people under hospice care are ready to die, to meet their Maker. Hospice from my perspective is a wonderful way to end life with dignity. Then there are those who want every last medical intervention possible to avoid death. End of life decisions by physicians, the dying patient and the families is a deeply personal decision.

  • Michael Hill

    When my great aunt died at 103, the death certificate, when translated, essentially said that she stopped breathing and her heart stopped beating. Old age.

    • Cassidy Dewberry

      I have a great aunt also died at 97 years old. She was previously having black stool and she had a colonscopy which showed an ulcer. They gave her antibiotics. A week later she feel asleep sitting on her couch. The cornor came in and said her heart stop beating due to old age. I still wonder today if she had a heart attack or stroke because she didn’t have to many health issues. She did have vascular problems with her legs and tremors. My question is can a person just die of old age? I don’t believe person heart just stops due to old age. Any comments?

  • http://www.gainesaying.com Sam Gaines

    Deeply poignant post. I can’t imagine the internal struggle of being an MD who is aware of an elderly patient’s poor health and poor prognosis, but is still required to administer the best health care available to try to keep him alive. I sometimes wonder if an expanded role for hospice doesn’t make more sense for elderly people who are this sick, but the sticky wicket would be what are the criteria for making that determination? I don’t pretend to know. Anyway, very thought-provoking post.

  • rezmed09

    Something is wrong. Not only with our health system, but how we treat the very old and infirm. We can’t let them die without all sorts of blood tests and scans and interventions which nearly everyone agrees are futile. And yet we do them. Why? I remember the great phrase from residency – long forgotten: “Don’t just do something. Stand there.” We cannot just stand still.

    In the teaching hospital, the justification is that these are “teaching cases.” Somehow this behavior continues to the extreme in hospitals throughout our nation. Unfortunately, in our consumerist mentality, saying “we did everything we can do” is more comforting and less litigious than saying “we did what is appropriate for someone his age and degree of debility.”

    But what the heck. This is America and everyone gets everything done, and no one pays -except later.

    • http://www.silvercensus.com jrh

      I agree with you here. We definitely need to shape up on our treatment of those growing old.

  • http://drgrumpyinthehouse.blogspot.com/ Dr. Grumpy

    I think a lot hinges on the individual patient, their comorbidities, their quality of life, and their mental status.

    We would make very different decisions for the 95 year old who’s demented and bedbound, vs. the 95 year old who’s active, sharp, and golfs twice a week.

  • http://nostrums.blogspot.com Doc D

    Recognizing when there is nothing useful left to do, is very difficult. By training, the impulse is to say that “we haven’t tried such-and-such,” knowing that it might be helpful, but likely won’t be. I’m haunted by the indeterminate nature of the value of a person’s life, to themselves and others, under these circumstances and the need to make difficult decisions…and that’s as it should be.

    For myself, having been witness to the passing of many over the years, I prefer to die at home, not in a hospital, or a hospice. I hope to be given the opportunity to choose the comfort of my familiar surroundings. Why is this commonplace of a hundred years ago now so rare?

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    I have watched many old people die. I live in an assited living/retirement home. I have seen sweet deaths, violent deaths and unpleasant deaths. What strikes me, speaking as a layman to a doctor, is that death is in the eye of the beholder. The same type of death can be perceived as good by some and hell by others. I wish more families would have conversations about death long before the moments come. We are allowed in the USA to live life with much freedom. We are given much freedom about our death. We squander that precious freedom to choose while we are mentally alert to consider all the possibilities. To put such choices on doctors is unfair and plain stupid. I always have hated to hear, “died of old age,” I wanted to know what happened to the body. So much we don’t yet know about an aging heart or lungs or blood or BRAIN! It fascinates me. My great aunt is healthy at 103, but her eyes and hearing is mostly useless. (Both one day easily fixed.) What role does being isolated in a nursing home play? She was vibrant until then. I watch the seniors here dwindle from isolation, from seperation from life as they knew it. (I am 53 and here due to MS) Put a human in a box without love, without choice of food and how will they age? Even I have difficulty getting to Dr. appts. for mammograms or a colonoscopy—transpotation is a big issue. I don’t thing a swift heart attack is the best way “out.” I think there is a better way, now it is up to the (here I go) baby boomers to figure that out. The medical community, social workers, death will one day be an easier transition—but first we must connect the dots.

  • Tricia

    This make death panels seem like a useful idea.

    • Doc99

      Suppose the post were about a spry 90 yr old who needed a hip replacement?

  • http://drpullen.com Edward

    If a family physician who knew the fajmily had been the physician making recommendations instead of a neurosurgeon, I suspect they would not have encouraged surgery, rather had a discussion of realistic expectations, aspirations, and what this gentleman might want. I don’t know many 93 year olds who would want this surgery if they knew that the outcome that came to be was even a possibility, instead of the “hoped for success” in this case.

  • Doc99

    They used to call pneumonia “the old man’s friend.”

    • http://www.silvercensus.com jrh

      Why would they do that? Just curious. This article definitely is in need of caring and love for those who lived thier lives for others.

  • Cheryl Gajowski

    Good insight. A related story -
    My (sort-of) father-in-law Joe had a pacemaker implanted after he collapsed in a restaurant on a trip to Florida….on a Friday night. Over the weekend he didn’t improve, and at first there were some assumptions about age and recovery time, not the point here..( as in would timely attention to his symptoms made a difference?)
    ON Sunday, it was determined that he had suffered a stroke, resulting from a clot, related to the implant, which had knocked out about 1/3 of his cerebellum. In discussions about what to do, I believe it was a neurosurgeon who said to my sig. other, “If it was MY father, i’d operate… ” They did , and he lived for almost 8 more years – from age 96 to 104. Sounds great, right? Not exactly. Joe had been an exceptionally with-it, and healthy, elder, involved in his investments, politics, family. The process of “healing” was unending, and he was permanently changed, disoriented and physically limited. And not in physical pain, but frustrated. The incredibly dedicated family provided most of the care – which otherwise would’ve required a nursing home. One thing that all the family agreed upon – even his wife, who would not have let him go – was to accede to Joe’s wish that he never see the inside of a hospital room again. And my “other,” Joe’s son – rued the day that he decided to go with the surgery, and forever felt it would have been better for his father to have let him die when the massive stroke damage was discovered. Personally, I wouldn’t care to live on so helplessly.

    The way to go – as if we had a choice – a 102 yr old great aunt was found dead, at home, of a sudden heart attack. Now that’s old age!

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I think that we see the ‘forest’ very clearly, but we forge onward regardless. Physicians are subjected to many forces, internal and external, that push medical care across the Rubicon.

  • jsmith

    Was the family doc involved? Was there a family doc ? Sometimes (not always) aggressive and futile care at the end of life can be stopped if the primary care doc has had this discussion previously, or if he or she is there to talk with the family. Unfortunately, for reasons we all know, this often does not happen.
    The ER, the hospitalist, and subspecialists are often in a fix here, not knowing the pt and family, etc. And, of course, sometimes families want everything done even when we think it is hopeless. But often the PCP can help pts have a better death.

  • TrenchDoc

    It reminds me of my 93 year old patient who demanded and eventually got a CABG for his chronic angina. He survived another 5 years until he committed suicide after the death if his wife. Was it justified and cost effective? Medical social issues that no one has the correct answers for.

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    I think we walk a slippery slope when we put a price tag on life. How much is one year worth? You can die at any second. Such decisions should be left to those facing death and WHOEVER decides, can’t we somehow stop counting dollars? We are the richest nation in the world. If you have lived past 65, you have more than paid for a chance at another year.

    • http://www.gainesaying.com Sam Gaines

      Diane: With respect, I think we’re no longer in a position not to count dollars; if we are the richest nation in the world, it’s because we’ve leveraged out future to create “wealth” out of thin air (hence the current roll of financial crises). As the Pete G. Peterson Institute and many others have pointed out, health care is devouring more and more of our GDP; at the current rate, nearly the entire federal budget will be devoted to Medicare/Medicaid/Social Security by 2050, leaving zero for defense and every other necessary (or unnecessary) fed budget item, to say nothing of the damage it will do to our personal income. So this becomes the question: Is one more year for the 85-year-old worth more than basic care for the 5-year-old? So yes, in the ideal world decisions would be left to individuals; but in fact, many individuals don’t file the necessary legal paperwork to indicate what their desires are should they face potential end-of-life choices. No easy answers here, to be sure, and tough decisions await us in the years ahead.

  • Not Savvy

    @Was there a family doc ?

    We patients, at those moments when we are most vunerable, are abandoned by family docs.

  • http://www.silvercensus.com jrh

    Taking the best care and committing a life to whatever one is best at is by far the greatest medicine.

  • http://www.drjohnm.blogspot.com DrJohnM

    “I can’t imagine the internal struggle of being an MD who is aware of an elderly patient’s poor health and poor prognosis, but is still required to administer the best health care available to try to keep him alive.”

    The decision on when to unleash the fury of modern technology onto an elderly or chronically ill patient has evolved into one of my greatest challenges. We can, so should we?

    It was easier early in my career. I knew medicine, but not real life. This was before a wife practiced palliative care. Before, Staci and I (primarily Staci) helped care for a neighbor with chronic diseases of aging, like Parkinson’s. And, before my ninety year old grandfather lived in our home for months. And before, I watched ICD patients succumb to the ravages of non-cardiac diseases. Before, I understood the concept of how “if you give a mouse a cookie,” pertains to caring for the aged.

    It is rarely the medical-legal that compels me to unleash modern technology on a patient, but rather, the notion that not doing so may be unjust.

    Mastering the obvious is essential in these matters.

    When it is possible to explain said conflicts to the patient or family, things are good, as they decide. When the patient or the family delegates the decision to me is when things are hard.

    As is often the case, the “comments” are the best part of the posts.

    Thanks

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