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In this episode, we welcome Alan Lindemann, an obstetrics-gynecology physician, to discuss the issue of autonomy and treatment for elderly patients. He shares his experiences in the long-term care setting, and the disturbing trend of interpreting do not resuscitate (DNR) orders as orders not to treat a patient. He recounts instances where elderly patients were denied treatment and left to die, despite their wishes to be treated like a younger patient.
Alan emphasizes the importance of respecting patient autonomy and making sure that elderly patients are not denied medical treatment simply because of their age. He shares a heartening story of successfully treating a 95-year-old patient with urosepsis and restoring him to his previous state of health.
Join us for a thought-provoking discussion on the thin line between “do not treat” and assisted suicide and the need to ensure that elderly patients are not denied medical treatment based on their age.
Alan Lindemann is an obstetrics-gynecology physician.
He shares his story and discusses his KevinMD article, “Breaking the silence: a doctor’s plea for clarity in end-of-life care.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Alan Lindemann. He is an obstetrics-gynecology physician. His KevinMD article is titled “Breaking the silence: a doctor’s plea for clarity in end-of-life care.” Alan, welcome to the show.
Alan Lindemann: Yes, thank you, Kevin, very much.
Kevin Pho: So we’ll get into your article in a little bit, but first off, just briefly share your story and journey to where you are today.
Alan Lindemann: Well, tomorrow I’ll be 75 years old. I grew up in a small town, on a small farm in North Dakota. Our nearest town was 20 people, so most people can’t even imagine that. My dad died when he was 39. He always said, “Life begins at 40.” I was one month into 11, so I very soon developed an interest in life-and-death matters, and I was always a serious young guy to begin with. I was the oldest of three, and so I assumed a position of responsibility, and I also recognized vulnerability, and that’s what drove me to my career.
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Kevin Pho: So tell us, what’s it like to practice in a rural setting?
Alan Lindemann: Well, one of the problems that we have in rural America is that we have to be a jack-of-all-trades. So people keep asking me, why is an obstetrician talking about nursing homes and deaths? Well, that’s because we practice here the way it was probably done 40 to 50 years ago, where you did what you had to do. And one of the biggest problems we have is getting our patients sent out, especially during COVID.
Kevin Pho: Give us a story or case study or an example of that.
Alan Lindemann: Well, years ago we could send out patients easily, but now with COVID, you could spend hours on the phone trying to get a patient referred, and you may not even be able to do that. So sometimes people even die in the process of trying to get them out of here. And we have to be good at many different things, all the way from intubation of little people to intubation of big people.
And then of course, for the most part, COVID wasn’t a real big problem here. We managed most of our COVID patients in the clinic, but we had a lot of COVID patients for a while. No longer that many. So yes, it’s lonely now.
Kevin Pho: Now, from an obstetrics-gynecology standpoint, just give us an idea of how the rural setting affects your specialty in particular.
Alan Lindemann: Well, of course, there are getting to be more and more obstetric deserts, and again, the problem is referral. For example, when I practiced in Fargo, which of course is much bigger than where we are now, I had my own ultrasound machine in the office. But of course, here we have ultrasound coming on Mondays. So it’s a very different way. We are deprived of a lot of the equipment and the assistance that we need to practice. But the thing about obstetrics is you have to love it, and you can’t be afraid of it.
Kevin Pho: All right, so let’s talk about your KevinMD article titled “Breaking the silence: a doctor’s plea for clarity in end-of-life care.” Now, how did this article come together?
Alan Lindemann: Well, we talked a little bit before about vulnerability. I’ve always been aware of how vulnerable young people are, babies, but also I’ve spent a lot of time now managing nursing homes, and the young and the old have that in common: They’re vulnerable. So when this 93-year-old man told me he wanted to be treated like a 73-year-old man, I could understand that. And I also understood that because he could ask that question that way, he had some ability to think and consent and also refuse treatment. So he was mentally with it.
Kevin Pho: Now, what did he mean by that? When he told you, as a 93-year-old man, he wanted to be treated like a 73-year-old, what did he mean by that?
Alan Lindemann: Well, sometimes what happens with people when they get older is we confuse the terms do not resuscitate and do not treat. And he understood that there was a difference, that he wanted the same treatment we would give to a 73-year-old, and he wouldn’t want us depriving him of treatment because he was 93.
Kevin Pho: Now, what would be some examples of those treatments?
Alan Lindemann: Well, for example, simple things, even like a bladder infection. One of the problems we have in a nursing home, or for that matter even when people get to be over 70, is they get a bladder infection and they get confused, and then the people around them say, “Oh, well, he can’t make any decisions. He’s confused. So let’s just let him die.” So we can have people dying from bladder infections, and of course pneumonia too. So yeah, he knew what he was talking about.
Kevin Pho: Now, from this patient’s experience, had he had specific treatments refused to him because of his age?
Alan Lindemann: I think that as long as I was there helping him, he got the treatments he needed, but he was worried about it. And yes, I think that probably because of who he was, maybe they tested his urine a little bit later than they might have with somebody else. I’m sure he had, I mean, I don’t know exactly where he was coming from, but I do understand that he knew what he was talking about.
Kevin Pho: Now, from your experience in the nursing home, how common is that scenario, where people who are able to make their own medical decisions but are perhaps in their late 80s or 90s aren’t being treated? Is this fairly common from your experience?
Alan Lindemann: I would say it’s quite common. One of the problems we have in nursing homes is that we get used to people dying, and you get kind of immune to it. And as far as I’m concerned, when we get to the point that we don’t take somebody’s death seriously, if we aren’t bothered by it, we should go on to doing something else.
Kevin Pho: So you mentioned earlier the difference between do not resuscitate and do not treat, and sometimes the line becomes blurred. So tell us, what are the differences between the two in your mind?
Alan Lindemann: Well, for example, we’ve been talking about pneumonia. And also, I’ll give you the example of somebody who came in. I didn’t take care of this patient, but she was do not resuscitate, but she was having an asthma attack, and she was in her 80s, and her family came with, “Oh, do not resuscitate.” So that meant we couldn’t intubate her, or they couldn’t intubate her, and she couldn’t be sent anywhere. So there was confusion there, and I think there’s a lot of confusion. It’s a slippery slope. It’s easy to go down the wrong way here.
Kevin Pho: Now, what can clinicians do to prevent scenarios like this from happening?
Alan Lindemann: Well, I think, first of all, everybody needs to know that there is a difference. We should never, for example, decide to not treat somebody for a bladder infection. Although the news that we’re getting from Washington, D.C., is we’re not supposed to diagnose bladder infections. On the other hand, we’re also not supposed to have urosepsis. So we have that political process playing into this.
But yes, I think that every time somebody gets confused, we should be thinking in terms of sepsis. We should be thinking in terms of the most common thing, which, like I said, would be a bladder infection, kidney infection, or urosepsis. So yeah, we need to think about that, and we need to make sure that we don’t get those things confused. I think that doctors and nurses need to understand that, and also the patients need to understand that, and the relatives.
Kevin Pho: So let’s ask that question another way. What can patients do to make sure that they’re not subjected to do not treat when they should, in fact, be treated?
Alan Lindemann: Well, that’s more complicated. In the first place, the patient has control as long as they’re not in the nursing home. In other words, if I have an 85-year-old presenting to the emergency room, that person is probably going to get a different kind of care than in the nursing home, because they’re not going to be automatically dismissed based on their age. The patient needs to come in, and the patient needs to explain what’s happening.
Kevin Pho: Now, cases like these, like the one that you told in the KevinMD article, how has that changed how you treat patients?
Alan Lindemann: Well, one of the things I have to do is try to ignore some of this stuff that comes out of Washington, D.C. In other words, when I was being trained 45 years ago, we were supposed to identify bladder infections. We were supposed to treat them vigorously for 10 days. Today, of course, we’re not. We’re supposed to ignore them. We’re supposed to treat them for three days. So things are very different, but I’m an old doctor, and I still remember the way things used to be.
And one of the things about medicine is that you can do a 180-degree turn in not a lot of time, and usually the truth is in the middle. You stay out of the extremes. So listen to these people who come in with their complaints, their bladder, whether it’s a urinary tract infection, whether it’s burning in this area, whether it’s a change of mental status. They should be treated or identified.
Kevin Pho: Now, what about your other clinician colleagues? Do you see them kind of falling into that trap, so to speak, or are they pretty cognizant and aligned with what you’re seeing?
Alan Lindemann: I think that there’s an awful lot of doctors who do just exactly as they’re told to do. And I know that, I mean, that’s one of the things about being my age: I don’t always have to do exactly as I’m told to do, and so I can make up my mind based on the individual patient who comes to see me. But yes, there’s an awful lot of doctors who do exactly what they’re told to do, and sometimes it’s not very good advice.
For example, PSA testing. We were told not to do that, and oh my goodness, look what happened: We’ve got no prostate cancer. Well, of course, five years later there’s a lot of prostate cancer, and it’s not treatable. So yeah, we get a lot of bad advice we don’t have to follow.
Kevin Pho: Now, give us an example of some of the pushback you may receive, because sometimes, you’re right, medicine is becoming more what we call cookbook-driven, algorithm-driven, guideline-driven. Now, sometimes pushing back against that can be difficult, especially not in rural settings but in larger organizations. So how can doctors push back against some of these guidelines that they individually may not agree with?
Alan Lindemann: Well, it’s very difficult to push back. For example, we have something called antibiotic stewardship now, where if you treat people with an antibiotic for, like, a bladder infection, that’s considered the wrong thing to do. But we can all make up our minds. Naturally, we’ll probably have to face some fallout. I mean, we may be listed as not being good stewards of antibiotic use, but I think we have to be willing to take the heat for that.
Kevin Pho: We’re talking to Alan Lindemann. He’s an obstetrics-gynecology physician. His KevinMD article is titled “Breaking the silence: a doctor’s plea for clarity in end-of-life care.” So Alan, obviously you’ve had decades-long experience in medicine, especially in a rural setting. Now, for those new doctors, residents, interns, and medical students who may be listening to this, what’s one piece of advice you could pass on to them?
Alan Lindemann: Well, I’d like to say: Make up your mind, have your own opinion, and be able to take the heat for maybe not conforming to every single thing that comes along. We still have to think.
Kevin Pho: And my final question: Just tell us some take-home messages that you want to leave with the KevinMD audience.
Alan Lindemann: Well, all of us will eventually be faced with our own mortality. We will all eventually get to the point of maybe signing one of these POAs, or whatever it is. But for the sake of our patients, we need to really define that, and we need to define it for the patients, and we need to define it for the relatives of the patient.
But there’s another message here, and that is for yourself. I, for example, know very clearly the difference, and I will go down fighting for the difference when it comes to my own life. And I think I may sound selfish, but I want to die at home.
Kevin Pho: Alan, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.
Alan Lindemann: Thank you very much, Kevin. Thank you.
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