Monday, January 11, 2016

Ethical discussion for the board

I think I have a general idea of how old most of us here are, I gather that outside of me and Funky, most here are in the boomer demographic. As I set out on a new chapter in my career, I feel like there is no doubt that the boomer demo is going to reshape and reconfigure how we think about medicine. When I take care of great generation seniors in hospice, the ones who still have their wits about them tend to be very blunt and matter of factly say things like, "It's time to go, I'm ready". This is a group of people who are very proud, and very independent and when their independence and ability to be self sufficient is gone, they want to die. I'm not entirely sure how the boomers are going to handle this.

My view of a lot of the great generation is that not being independent is basically the same thing as being dead. They don't want to be a burden on anyone. Some boomers I take care of are pretty matter of fact about things and embrace the idea of quality of final days versus quantity of final days. But, with the advances that keep occurring in medicine, I think boomers are going to have a plethora of options open to them that previous generations did not. We already can keep a person alive well beyond the point where they are unable to care for themselves. But, up til now, there hasn't really been much discussion on whether we should.

We've sorta talked about this before here, but I'm curious to get an update on where people stand these days. Should we always keep a body functioning as long as we can, just because we can, or should we start to consider if there should be some limitations on how far we go with treatment? I suppose this gets close to the death panel discussion, but to address that directly, should a doctor be able to convene an ethics committee and based on the findings of that committee tell a family or patient that they are not going to continue aggressive treatment? At the least, does it seem like we have reached a point in medicine where a patient should be given more options to pursue treatment that is purely comfort oriented rather than treatment that is meant to prolong their life as long as possible? Thoughts?


  1. Hey Max.

    A great issue.

    A story.

    My wife has a great uncle, 92. You name it he has it from a mild case of dementia. High blood pressure, cholesterol, etc. Recently he had a stroke and they notice his heart was having difficulty. They said after he recovered from the stroke he should have a pace maker. The children, one a lawyer, another a nurse began harassing the doctor to immediately give him a pace maker. To avoid a potential law suit he complied.
    3 months later he still has issues from the stroke. Still in the hospital.

    As they say, 70% of medicare are spent of 10% of the people. 30% of medicare spent on the last 2 years of life.

    This is what we are faced with, not a person who wants to extend their life but the relatives that refuse to let a person go.

    1. I'm reading a really good book right now that I will do a review on soon when I am done. Patient's like your uncle are universal, IE they present to the hospital everyday. I've found that family members who are professionals can be very difficult to work with. I try to say it's because they just want to make sure all bases are covered, but sometimes I honestly believe it's just their ego and desire to make sure they know everyone else knows they are smart. And also, I think they are people who are frequently used to being in charge of a situation. Frequently, it dose become entirely about what the family wants, and I've had quite a few family people tell me directly they don't think the patient wanted that level of care. Whether a doctor is afraid of getting sued or not, I think that most do not want to go through the confrontation of telling a family member their expectations are simply not realistic.

  2. I and my wife both have end of life directives stating that we do not want to be placed on like support if there is no hope of survival. I am reminded of the Terry Shaivo case where many Republican law makers, including Jeb Bush, interfered in the case and demanded that she be kept on life support, even though her doctors had confirmed that she was brain dead. This was a prime example of politicians interfering in a tragic family affair where they had no business, for some perceived political gain.

    1. First of all Mick, Happy Birthday! Hope you are enjoying your day. I might do a fuller post someday on this, because I feel very strongly about it. Advance directives are a good first step, but they still leave enough wiggle room to get a person to a point they never wanted to be at. The Shaivo case is kind of a good example. Technically, she wasn't brain dead, though she was in a vegatative state. She had lost all the cognitive function that makes us who we are, and was also blind. But, she did possess enough lower brain function to keep breathing and make primitive responses to stimuli. I think most people consciously accept for themselves that they do not want that, but it's easy to get there.

      Advance directives by themselves are not always binding. The most important thing is to have a surrogate named who will make your healthcare decisions if you are unable. Just I have seen some bad situations, I have also seen situations wherein a patient named a surrogate completely outside the family to make their decisions, and they chose wisely because the family members were infuriated that they were not allowed to do what THEY wanted regardless of what the patient wanted. Shaivo had no hope of recovery, but they could and did keep her body functioning. If you have a surrogate named, you have a much better chance of having your wishes adhered to.

  3. By the way, today is my 77th birthday.