We don’t really get to die of old age

Whether they are young or old, we do not want our loved ones to die.  Period.  Even if we live with faith in our eventual, eternal reunion with them, we know that their passage will leave a void.  I completely understand.

But I want to take a few lines to try and make things clearer, or easier, for those who have family members who are very aged and infirm.  You see, I am privileged to care for many seniors in the emergency department where I work.  And a large number of those I see come from nursing homes.  Furthermore, many have severe illnesses that have left them debilitated, such as profound dementia, life-changing strokes or heart failure, cancer, kidney disease and various physical ailments.

Very often, when they become acutely worse, they are sent to hospital emergency rooms.  Sometimes, this is due to the concern of family members.  Other times it is due to the policies of the facility where they reside.  But all too often, the trip to the ER and the evaluation there is uncomfortable and frightening for those patients in the final phases of life.  And the expectations that come with those experiences are unrealistic.

It isn’t that they cannot, or shouldn’t, be treated.  It’s easy enough to give fluids to the dehydrated, to treat the pneumonia or urinary tract infection.

But what I want everyone to think about, when their elderly loved one is sent to the ER, are these things:  1) What do I want to have done? 2)  What outcome do I hope to see in my family member?  3)  What am I willing to put that person through? And 4) what would they realistically want if they could say?

For example, when the sweet, 95-year-old lady with dementia has a heart attack, will her family want her taken to the cardiac catheterization lab for a procedure? Even if they say yes, the cardiologist will likely say no, due to the level of risk involved.  She may or may not survive the event, but the procedure may be just as bad.  And if the 85-year-old, bed-ridden gentleman with multiple strokes falls, and hits his head and has a hemorrhage in his brain, will the family expect him to have a craniotomy (open brain surgery) for the injury?  Will there be a net improvement in his life, or an extension of his years?  Will the darling great-aunt with heart failure and pneumonia survive the month on a ventilator?  And would she want it?

Please understand that I’m not advocating “mercy killing” or anything as nefarious  as that.  I want everyone to have as much time, and as much quality of life, as possible.  But we need to be merciful and realistic.  And even those working in nursing home facilities need to be practical.  A nurse once told me that she wanted an elderly patient taken to the ER for pneumonia, against her family’s wishes. I asked her, “How do you want to die?”

Her answer was telling: “Why, of old age, of course!”

We don’t really get to die of old age. We all die of something. But we can die with dignity and comfort. And our loved ones deserve a chance to die without unnecessary interventions born of unnecessary guilt or false expectations.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test

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  • John C. Key MD

    Good post…and the goals stated are worthy. What is required to make it work? Physician leadership. Courage to make and recommend tough decisions. “Do everything” is the easy way out but yields the poorest result.

    • medicontheedge

      True, Doctor… so get your peers to take the helm at nursing homes, where most of the problems lay.

  • Steven Reznick

    Exc ellent post. Like most things we need better education and discussion with non medical individuals about end of life issues and choices. We next need tort reform for nursing homes and assisted living facilities so that they actually care for patients on site and try to keep them comfortable without being pressured to call 911 and ship the patient to the ER out of fear of an elder abuse suit. We need practitioners to treat what is treatable and reversible such as infection. We need to return end of life care and palliative care to volunteer groups and faith based groups rather than for profit corporations running hospices. These woul be good beginnings.

    • medicontheedge

      Spot on about the nursing home issues… but you assume incorrectly that these facilities actually provide medical care. THEY DON’T.. At best, they attempt to provide the minimum standards for safety and nutrition, and pass the 30 meds each patient takes. Anything outside the “norm” for that patient results in a trip, an expensive trip, to the ED, no matter what time of day or night, weather, and even the patients wishes. Total reform of what we call “nursing homes” needs to begin.

      • Steven Reznick

        I have proposed a national health service in which all physicians in training, nurses in training and health care workers are enrolled for 24 months before they can go into specialty training or go into the world and practice. Their training program would be providing the oversight. They would be placed in skilled nursing facilities, public health centers, adult and child health care centers, schools as nurses. The idea would be to provide care at the facilities rather than in emergency departments and acute care hospitals, provide care and education in schools and public health facilities. It would additionally give the doctors and nurses a general medicine experience and perspective that would serve them well in understanding the problems of both general medical patients and practitioners outside their chosen area of expertise as their professional careers become narrower. In exchange for their service the health care participants would be given some form of educational loan forgiveness. If a practitioner goes into primary care and stays there for 15 years in a well served or underserved area I would give them complete loan forgiveness. With a young enthusiastic group of talent in these facilities we can begin to perform the services and begin the reforms needed so that the young and elderly receive excellent care.
        Yes tort reform is necessary in the nursing homes. There should be no relief for those willfully and criminally neglecting their responsibilities and duties but care and clinical decision making should not be made on the basis of fear of a suit. Most of these facilities have one RN per 40 patients so how is that RN’s skills and experience going to be best used with that kind of workload?

    • http://seniorlivingwatchwordpress.com/ Janms

      No, no, no. We’re not going to use our need for end-of-life planning and advance directives as another excuse for nursing home tort reform. Fear of litigation is one of the few things that keeps nursing home operators from neglecting to hire any staff at all. Tort reform will further deteriorate the already poor quality we have in many nursing homes today.

  • ErnieG

    I was once told a joke about an old time doctor talking to a young one. The old time doctor was saying how much medical knowledge has advanced since he was a student. In the past, we did not know what the patient died of, perhaps old age. Nowadays, with all the advances, we know exactly what the patient died of.

    • rbthe4th2

      Except when the cadaver is checked, we find missed/delayed diagnosis 10-20% of the time. I’d say it might be best guess?

  • maggiebea

    My mother died of old age, more or less as she wished, a few months short of her 90th birthday.

    Her chief complaint in her last few months was the excessive caution of her caregivers and the interventionist tendencies of the local healthcare system.

    Addressing yet another ‘young whippersnapper’ (say, a hospitalist half her age, and therefore at the peak of his career as an ER attending), she would repeat, “But if you keep preventing all the easy deaths, I’ll have to die a hard one.”

    She said she would have preferred a simple pneumonia to be left untreated, if she couldn’t just die in her sleep.

    When I’m called upon to help a mildly demented elder cope with arriving yet again in the ER, I can’t help but remember what she said.

  • Rob Burnside

    I like the Society of Friends approach–”Moderation in all things.” To include all things medical.

  • medicontheedge

    Hear hear! Every shift I am forced to do insulting and painful, and all too often futile, things to elderly infirm people who often HAVE NO SAY in their care. It breaks my heart… I want to take their families by the shoulders and shake some sense into them. And don’t even get me going on the abysmal conditions, policies, and goings on at the nursing homes.
    BUT, I also realize, these elderly infirm are often cash cows for my hospital. Sad, but true.

  • Bob

    I believe your putting the emphasis on the wrong thing all together, believing the majority of the elderly want to live long lives.
    My experience is just the opposite finding they all only want to live as long as they are living quality lives, while many families cling to them for sentimental reasons, perhaps.
    Talk to nursing home residents and ask them what they want and I believe most will say 2 things: 1) to go home, and 2) to die as they no longer have quality in their lives.
    The ones who are sent to the hospital are sent there for these purposes, I suggest.

  • leslie fay

    AMEN! I am a retired respiratory therapist. My co-workers and I used to say that at some point in time “pneumonia is my friend” I don’t remember who said it but “American’s think death is optional” is so true. It’s really sad what people ‘do’ to their loved-ones, not for the patient but for themselves. For various reasons. Not all are noble.