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Ugly Politics & End-Of-Life Care

Death panels.  They are all the trend these days.

I went to Home Depot to look for some, but couldn’t find any.  There was some drywall of doom, tiles of the abyss, and sheet rock of destruction, but no panels.  I guess the Obama administration has bought them all.

Honestly, I am not sure what the “death panel” fuss is about.  Everyone dies.  There are times it is a surprise, but many times it is expected.  When it is expected, shouldn’t people plan for it?  Shouldn’t we encourage people to plan for it?

The focus of a physician is twofold: to prolong life and to minimize suffering.  We practice preventive medicine to keep the person from avoidable pain and/or death.  The younger the patient is, the more we call their death things like tragic, pointless, and distressing.  We go to great lengths to save the life of someone who has many potential years ahead.

But there is a point when things change.  There is a point when the focus shifts from quantity of life to quality of life.  There is a time after which a death is no longer tragic, but instead the end of a story.  My focus as a physician shifts from trying to find and prevent disease, to maximizing function and minimizing pain.  When does this happen?  It depends on the health of the patient.  But eventually, ignoring one’s inevitable end becomes more tragic than the end itself.

I had a man in my practice who had advanced Alzheimer’s disease.  I cared for him before he started his decline, and so had a good chance to know both him and his family.  They were people of strong faith, accepting the hard things in life as being from the hand of God.  The children took their father’s condition not as a horrible burden, but an opportunity to pay back the man who had given them so much.  There was no fear of illness or death.

His wife died fairly soon after I started caring for them.  He grieved greatly when she died, but was so surrounded with the love of their children that his grief was short.  He spoke often of her in subsequent visits, talking about her as if she was not far away.

As he became increasingly short in his memory, my relationship with their children grew.  You can tell a lot about people from their children, and these children were a dazzling crown of honor to these two lovely people.They always came asking good questions, patiently dealing with their father’s confusion, anxiety, and occasional outbursts.  Together we worked to maximize his quality of life.  When I suggested we stop cholesterol medication and cancer screening tests, they understood.  Our focus would not be on the length of life, but the quality of time they could spend with their father.

I was shocked, therefore, when the report of his admission to the hospital came across my desktop.  He had chest pains and some difficulty breathing.  In the emergency room, a plethora of lab tests, x-rays, and other studies were done.  The hospitalist physician on call felt there was a good possibility of heart attack or pulmonary embolism (blood clot to the lung).  My patient was sent to the ICU, where he underwent CT angiography, serial lab tests, and even a stress test to rule out heart problems.

I was mystified as I read these reports; the family clearly understood that prolonging his life wasn’t the goal. The patient was ready to die and join his wife, and the children were very comfortable talking about his eventual death.   These reports made absolutely no sense with what I knew of this man and his family.

He looked his normal self when he came in to my office for a hospital follow-up.  I questioned the daughter about the details of the admission, which she recounted carefully.  Then I paused and asked her, “Can I ask you one more thing?”

She smiled at me, “Of course, Dr. Rob” she said gently.

“I was honestly a little surprised when I read about your father’s admission to the hospital.  It seems like they pulled out all the stops, even putting him in the ICU.  Did they ask you if this is what you wanted?  I thought that you wouldn’t want to be that aggressive.”

She thought about what I said and a puzzled expression slowly appeared on her face.

“Did you ask to have everything done, or did you just follow what the doctors at the hospital told you?” I asked.

“They didn’t ask us.  We just did what they told us we needed to do.” she said, now scowling slightly.

I explained to her that they need to make their wishes known in advance.  If they don’t say anything, the doctors will assume that you agree with what they are doing.  As I told her this, she nodded and looked down sadly.

“It’s OK what you did” I reassured her.  I patted her father on the shoulder and added, “he looks great now.  I am glad I get to see him again.  I just want you to know what to do if it happens in the future.  You never know what will happen, and I’d hate for him to suffer needlessly.”

This one short hospital stay undoubtedly amassed a bill many times that of all my bills over the 12 years I saw him in my office.  My years of care, long conversations, and real personal connection built with this man and his family are worth only a fraction of a few days of unnecessary care.  This care was not demanded by the family.  It was not done because of denial or ignorance; it was because the family wasn’t prepared for the mechanics of the hospital stay.  I never had that conversation with the family until after this event.

Politicians have labeled this merciful conversation as an act of rationing.  That is not only ignorant, it is shameful.  Talking to people about end-of-life issues will certainly save money.  But it’s a contemptible step to imply that this money is saved by killing the elderly.  It’s more wrong to make money off of keeping them alive unnecessarily than it is to save money by letting them die when they choose.

This is politics at its ugliest – taking a provision that will reduce suffering and help people and pervert it to be used as a tool to scare the people it will help.  The discussion about healthcare has been subverted by those who want poll numbers.

Shame on you.

*This blog post was originally published at Musings of a Distractible Mind*

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