Why you should have your end-of-life discussion now

Draping a shroud of 30’s Depression on any dust bowl child can thicken the skin, so my 88-year-old patient learned to be fiercely independent with a “talk to the hand” attitude, and “don’t get in my way” personality.  Even after her husband passed away, she remained autonomous traveling and golfing in her social circuit.

Living life as a smoker was always a threat to her health, and this year became a challenge as she continued to make it through hospitalizations, and return home.

With each admission, she advised me “I want everything done.”  An advanced health care directive was presented, designees were made should she not be mentally able to make health care decisions, and details of her full code status were always on the medical chart.

Entering her hospital room, I found her respirations labored, so a code blue was called placing a breathing tube.  I was surprised by the staff response as the surrounding talk was, “Why are we coding this 88 year old?”, and “She should be a DNR!”

Someone then commented “she said she wanted to die,” and apparently a staff member was calling the health care designee to change the code status.  This is the duty of her physician, and I, therefore, advised everyone the wishes she had detailed to me for over a decade.

Unfortunately, this staff reaction is pervasive throughout all hospital units, and especially applied to elder senior patients.  Most susceptible are those who have no end-of-life documentation, or when the admitting physician has not had this important discussion with the patient or family.

Because business has taken over medicine, one of the easy ways to lessen costs is to expedite hospitalized patients to end-of-life care.  Hospitals are paid a lump sum by Medicare, so they avoid costly intensive care units, decrease tests, and reduce patient length of stay; HMOs are able to financially wash their hands of their medical obligations; hospice care organizations enhance their business; and skilled nursing facilities (nursing homes) are now the final destination of the Greatest Generation.

Who makes health care decisions?  It should be the patient based on their personal hopes and needs, and the physician meshed with the realities of modern medicine.  Eighty percent of my geriatric patients have made up their minds and are DNR (do not resuscitate) and want no heroic measures taken should they stop breathing or their heart stops.  The other twenty percent are full code, or have specific interpretations of what they want at end-of-life.

I have this discussion with one hundred percent of my patients or families.  Since we now have a drive-thru medicine culture, my physician colleagues do not have time to have a conversation. Hence, it is up to the patient and family to assure end-of-life decision-making is made far before an emergency develops.  Over the past several years, the media has promoted this information, but simultaneously business interests have exerted pressure on health care personnel to move hospitalized patients rapidly into hospice care.

Here is advice that might allow you to make rational emergent decisions in your best interest:

  • Have a discussion now with your family or friends what you want concerning end-of-life decisions.
  • As memory problems sometimes comes with aging, have this discussion while you are mentally capable.
  • Read and formally fill out your decisions into advanced health care directives, durable power of attorney, POLST, living wills, five wishes, or other available forms.
  • Re-evaluate these documented decisions as you age, reflective of your health and quality of life.
  • Find a constant trusting physician who will facilitate your decision-making.
  • Have the documents of what you want readily available should you be hospitalized, and make sure you or your family informs the admitting physician and hospital.
  • Be leery of business tactics, even in a hospital or from a doctor, forcing you to make a quick or uncomfortable decision concerning your care especially if it is directed toward hospice or a nursing home.
  • This might be more difficult:  Be careful what you say, as literally for some reason, when hospital personnel hear “I want to die” (even if you are in pain or duress), they push the “hospice button” and a palliative care team or hospice group attempts to activate their services.  (Palliative and hospice are an invaluable part of end-of-life care, but when used as a money-saving tactic by business under the guise of compassionate care, can be a misplaced tool applied too early to the detriment of you or your loved one.)

Throughout health care, medical decisions are being made by insurance companies, hospitals, and HMOs, instead of your doctor.  But open discussions and early decision-making will allow you to avoid business tactics now being used against elder seniors.

For my patient, the breathing tube eventually was removed, and arrangements were being made for her to go home.  Just before discharge, she stopped breathing.  Without pain or discomfort, and at the behest of her health care designee, she passed away.

This is what she would have wanted.

Gene Uzawa Dorio is an internal medicine physician.

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