Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, July 24, 2009

On Tough Decisions

The topic of tough decisions has been raised by Buckeye Surgeon, who handled a difficult situation with care and finesse, and butchered (as usual) in response by Happy the Hospitalist.

After careful consideration, consulting with the patient, family, and attending physician, Buckeye proceeded to implant a port into a 92-year-old woman for chemotherapy to treat recurrent breast cancer.

After a superficial reading of the post and the relating of a completely non-analogous anecdote, Happy states that "being 92 and functional is not a good enough reason to abuse patients in their last few months of life..."

I shall take him up on his invitation and call him an ignorant, cold-hearted jerk.

In the first place, chemotherapy administered to a competent, conscious, cognitively intact 92-year-old patient after careful consideration and extensive patient education and discussion about side effects and outcomes does not constitute "abuse." Working up a 90-year-old patient with metastatic pancreatic cancer and recommending aggressive therapy, on the other hand, does.

The point I have made before (here) is that if we somehow managed to stop wasting time and money on futile care, aggressive end-of-life interventions, and expensive high-tech procedures never proven more effective than lower-cost treatments to patients of all ages, there would be plenty of resources available to provide appropriate comfort care and medical treatment to the vigorous elderly.

Buckeye's vigorous 92-year-old is the exception. Exceptional cases make bad policy. For every functional nonogenarian, there are dozens of nursing home denizens whose bodies are forcefully being kept alive even though their souls have long since departed. If we refrained from spending fortunes on ICU care every time they try to die become septic and just let nature take its merciful course, there would be no need to argue about taking care of spunky old 92-year-old ladies who still have all their marbles.


At Fri Jul 24, 06:01:00 PM, Blogger HMS said...

Medicine is a field of mystery (and a closed society even) to policymakers and fellow humankind.

At Fri Jul 24, 06:43:00 PM, Blogger OHN said...

Very well said...and timely for our family. We have a 90 year old aunt that we are custodians of, that up until last year was vibrant and lived alone, taking care of all of her ADL's. She suddenly and rapidly has declined, necessitating care from an assisted living facility (that every time she sneezed shipped her off to the ER) she has broken both hips (the second 3 weeks after the first trying to ambulate herself to the bathroom) and she is rapidly declining. We transferred her to a different ECF, that didn't have all the lovely amenities as the first, but the care is far superior. We had a conversation with the WONDERFUL ECF physician and we have all agreed that no more emergent trips to the ER are necessary. She knows her time is short and she has told us she is ready to go. Why on earth would we do anything more than comfort care?? Anything else would be torture for her poor body that is shutting down.

My point to this long comment is that two years ago, when she was still doing her own grocery shopping, cooking for her friends etc, she would have been one of those exceptional cases where significant measures would have been considered. You just have to know when enough is enough.

At Fri Jul 24, 06:58:00 PM, Anonymous Anonymous said...

I can't read HH. Makes me insane. I'm sure lots of people hate my blog, too.

Dino--had time to read a bit of the book while waiting in the drs. office. LOVE it. I especially loved the part about the Pap smear spatulas for "magic wands". I always joke with patients who seem to have a sense of humor that I left my magic wand at home. Maybe I'll have to try to find some of those!

I LOVE the rules, so I can't wait to read your take on them.


At Fri Jul 24, 09:02:00 PM, Anonymous Anonymous said...

How right you are.

At Fri Jul 24, 09:22:00 PM, Blogger Ninja Pharmer said...

I really think that Happy would be better off as an accountant or something where be doesn't have to deal with people. He seems to have difficulty switching off his analytical mode - he often seems to regard patients as nothing more than a series of systems rather than people with lives and wants and desires.

I'm starting to wonder if he's not descended from The Borg.

At Sat Jul 25, 09:21:00 AM, Blogger Nurse K said...

Happy is the KING of comparing apples to oranges and then backtracking and saying he was really talking about pineapple the whole time.

At Sat Jul 25, 09:36:00 AM, Anonymous Anonymous said...

It's a fall-back mode for someone who either wouldn't or couldn't choose between apple and orange.

At Sat Jul 25, 09:59:00 AM, Anonymous Anonymous said...

What frightens me is that very soon [if Obama gets his way], we will no longer have any choice as to whether elderly patients receive treatment and people who think like HH will be the norm; "just die, willya? We don't have the money or time to waste on you."

My God, what have we become?

At Sat Jul 25, 10:23:00 AM, Anonymous Anonymous said...

Nonsense. Just which part of "Guarantee Choice" does not make sense? It's idealistic, but hey, at least get the bullet points straight.

Medicare (social security too) is projected to run dry within 10 years. The scenario you mentioned would come true [frequently] if we ditch the reform and let our system rot on.

At Sat Jul 25, 10:30:00 AM, Anonymous Anonymous said...

Situation critical:

2017 (Medicare) & 2037 (Social Security)

At Sat Jul 25, 11:58:00 PM, Anonymous Anonymous said...

An extremely well-written update post, by Buckeye (Dr. Parks).

At Wed Jul 29, 05:44:00 PM, Blogger Allie said...

Wonderfully said. =)

At Wed Jul 29, 08:27:00 PM, Anonymous Anonymous said...

Hi Dino,

Love the post. I am a new grad nurse working in the ER and see lots of elderly septic patients knocking on death's door. I am wondering how many PMD's are having annual conversations with there patients regarding end of life care? Mostly everybody I see in the ER is a full code. I cannot help but wonder WHY?

Do you and your colleagues have annual end of life discussions with your patients?

On my end there appears to be a communication gap between what a code entails and what the return on resuscitation is with patients and their respective loved ones. Do you think the public at larger is aware of how violent a code is when performed upon an elderly person?


At Sun Aug 02, 04:41:00 PM, Anonymous Anonymous said...

My grandmother was diagnosed with colon cancer at 92. She talked the reluctant doctors into surgery. She did fine. She's 96 now, still loving life and her weekly poker games. I don't know how long she'll live, but I do appreciate that the surgery bought her more years of productive life. How horrible to think that some doctors would call her surgeon irresponsible or worse.


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