Message Font: Serif | Sans-Serif
 
No. of Recommendations: 2
Two weeks ago, I was visiting with a woman from our church, who was scheduled to go into surgery for an angioplasty. She was 76 and the main caretaker for her 80 year old husband who has parkinsons. She was discussing the upcoming operation with my MIL and me and said that she told her doctor: "I've probably only got a few years left anyway, why can't you just leave me alone? I really don't want to do this!" Her doctor replied that she'd better be careful what she asked for, as another doctor might very well leave her alone and where would that get her?

Well, the answer is that might have given her a few more weeks/months of relatively pain-free life, as opposed to two weeks in ICU, thousnds of dollars in hospital bills, and now a funeral and the question of what will they do about her husband?

On that fateful morning, this woman went in for a procedure that was supposed to take less than an hour, and she was supposed to get to go home at the end of the day. Instead, while on the table, her kidneys shut down. While trying to get her kidneys going, she had a heart attack. They got her heart going again, got her out of the OR, and she ended up in ICU. She never got out of ICU. She spent 12 days in ICU before she passed away Saturday morning.

My middle daughter was very close to her. She called her "Ms. Bobbie" and always made a point of running up to her and giving her a hug before services started. This dear little woman was only about 5 ft tall and her husband was over 6 ft. DD#2 had been greeting her every Sunday since she was in 2nd grade looking up at her to 10th grade, towering over her. She was one of two women who DD#2 looked on as an extra grandmother over the past 8 years. I'm now left to try to explain to her why, over Ms. Bobbie's objections, her doctor insisted that she needed this operation.

So my question:

Why is it that doctors are so hung up on extending life at all costs. Shouldn't there be some designated age that says if you pass this milestone, then all your treatment becomes optional? Why do we put our older citizens through all this? Bobbie was prepared to die, she didn't fear it at all. What she did fear was being in pain for no good reason, which is exactly how she ended her days. Whatever happened to "do no harm"?

LWW
Print the post Back To Top
No. of Recommendations: 2
Couldn't she have refused the treatment? I was under the impression that unless you are unconscious or mentally unstable, they can't treat you without a signature.
Print the post Back To Top
No. of Recommendations: 0
Couldn't she have refused the treatment? I was under the impression that unless you are unconscious or mentally unstable, they can't treat you without a signature.

She felt pressured by the doctor to go along with it. He kept arguing with her that it was her "duty" to take care of herself for her husband's sake. She felt a tremendous amount of guilt about not wanting to have the procedure done. She completely bought into the doctor's argument that "It's just a minor procedure and then you'll be right back to caring for your husband in a week or so."

LWW
Print the post Back To Top
No. of Recommendations: 0
LWW, I really feel your anger at this, and that makes me angry too! I'm so sorry this happened to someone you and your daughter cared deeply for.

Loving
Print the post Back To Top
No. of Recommendations: 37
RE: ".... I'm now left to try to explain to her why, over Ms. Bobbie's objections, her doctor insisted that she needed this operation.

So my question:

Why is it that doctors are so hung up on extending life at all costs. Shouldn't there be some designated age that says if you pass this milestone, then all your treatment becomes optional? Why do we put our older citizens through all this? Bobbie was prepared to die, she didn't fear it at all. What she did fear was being in pain for no good reason, which is exactly how she ended her days. Whatever happened to "do no harm"?"


So, the doctor wrestled her to the ground, sedated her, did the procedure over her objections, faked her signature on the witnessed consent form and somehow convinced/bribed all the other people on the team (the nurses, the admissions folks, her family) that it was all voluntary on her part ????

I understand that you are angry and grieving, but allow me to give you some perspective from the standpoint of an oncologist, who spends a lot of time with incurable illness, advanced age, and sometimes iffy risk/benefit ratios.

First, what a patient may choose to tell his/her family, bridge club members, and the guy taking the order in the restaurant does not always reflect what really happened. Sometimes, when people say, "Gosh, I can't believe they want me to do this!" that is really someone's cue to rush in and say, "of course you should do it! It's very safe and my mother did great with it!" OR "but we love you so much---we really want you to do it! we value you and think you are worth it" or some other reassuring thing. In this way, it's like the beauty queen saying how ugly her nose is...other times, a person really is "fishing" for advice and reassurance that it is OK for a person to choose not to do something, and that they should speak up to tell their provider what they want.

Secondly, if a person doesn't want to do something, whether that it taking pills, getting chemo, taking a blood transfusion, or getting surgery, all they have to do is JUST SAY SO. Same for CPR and ventilation (breathing machines). It is the doc's job to make sure they know all their options, and to give advice based on the risk/benefit ratio, age, etc., but in the end, it is the patient's choice, and that's what makes it a horse race. For example, among identical breast cancers, a pregnant 27-year-old will make a different choice than a healthy lady of 65, a healthy 75-year-old, and a broken-down, chronically ill person of only 60, with a very poor quality of life. Undoubtely, abuses occurred more frequently years ago, with the "doctor as god" attitudes on both the part of docs and patients, but those days are gone now, between medical training, the internet, changes in attitues among patients/families, the sheer volume of providers involved in complex decisions, and lawsuit concerns. I have to say that I have NEVER seen any coercion in the last 15 years in any of the patients I have seen, except by family. If the person doesn't want something, it is their responsibility to JUST SAY SO. Family can help with this as well. I did this with my grandmother, who clearly didn't want treatment for myeloma at age 94 but didn't want to hurt the doctor's feelings (!!!).

Thirdly, what one might choose rationally, coldly as a theoretical issue may not be what one chooses to do when one is actually confronted with a decision. I am sure that Superman would have shuddered and said, "heck, no!" if someone had asked him if he would choose to live, quadded off from the neck down, bloated and on a vent, and needing help for every bodily function. Yet when this happened, he chose to live that way for all those years---at any time, he could have simply said, "this is not for me" and he could have chosen to have those machines removed. I am not judging his choice; it was his, but my point is that when the chips are down, people may choose things that don't have a lot of benefit, either measured by longevity or quality of life. I am always astonished at the variance in my geriatric patients when I tell them that the value of "cure," at least time-wise, is much less for them than other patients. Some clearly see this makes sense and at least needs to be weighed into the decision, and others are offended at the idea that a "cure" that may be only months or years may not be worth it the side effects.

As an oncologist, I work tremendously hard to make sure that people know what they are dealing with: curable or not, side effects and effectiveness of treatment, other treatments available, what the non-intervention options are (Hospice/comfort care), possible timelines with each, etc. I try very hard to make sure that patients understand that it is THEIR choice and that not only will I respect it, I will do my best to make sure that their family members support it and don't hassle and 2nd guess them. I make sure they don't make snap decisions, and that they have lots of chances to ask questions, and that they know they can change their minds again, if whatever they have chosen is not what they want after all. I try very hard to be compassionate without offering false hope, and I tackle the tough questions, which is very emotionally draining, and so to have all doctors painted as "insisting that patients hang on to life at all costs" is not only inaccurate but offensive (although I am not taking it personally and know you are a cool person, LWW, from your previous posts).

Actually, my problem has always been the opposite, unrealistic patients and families who believe that they will be the exception because they "are a fighter" or have God on their side. Sometimes it's just denial (who wants to think about this icky stuff?), and often it is simply fear of death (which I find often exists even in very calm, rational 80-year-olds).

On my call weekend rounds ending yesterday, I saw (cleaned up for anonymity):

1 patient with widespread incurable cancer who wouldn't talk about "what if" for code status, and so if she does worsen, she will be put through horrific stuff that doesn't work (but on TV, a person is shocked and then they sit right up, lipstick on, and have a tearful family hug). Is this going to be MDs "forcing her to cling to life at all costs?" No, it is going to be HER choice because she refused to face making a decision. Or else, if she DOES survive it for a few hours or days on the vent, it will be her kids/spouse who has the tough job of allowing us to unhook her from the vent.

4 more patients with significant problems and poor quality of life, who had refused to switch to comfort care despite the advice of their oncologists.

2 in the ICU dying slowly with tubes everywhere, because they did not agree with the MD's recommendation that they accept a "DNR" status.

8 patients with complications of cancer and/or treatment, who are incurable but have decided that it is worth it. A few a not bad at all but most have a poor quality of life, which is apparently is acceptable for them (remember Superman).

1 new diagnosis with a widespread incurable cancer in an elderly person, who said, "I'm old, keep me comfortable." Not a singe MD or nurse is arguing this rational decision.

1 person who signed out of the hospital against medical advice with multiple things that are potentially life-threatening. It is not a smart choice (this isn't even cancer and the patient is young) but it IS HIS choice, so off he went.

1 person who has been in the hospital for 60+ days ("a fighter") who only just now is coming to the conclusion that maybe the docs are right and this aggressive care which that person chose maybe ISN'T worth it.

1 of mine (the rest belong to others) who is in for a complication of my treatment. Incurable disease, and the treatment is not standard in that this person could not stand aggressive treatment, and the only goal was to live long enough for _____ family event in 3 months. The person knows it is incurable, but wanted to live long enough for this one event, and in fact is much better than before we started. Will it last? No. Is it worth it? Yes, to this person. Were there more aggressive, "clinging to life" options? Absolutely, and we explored them all, and this was the choice, which X can change at any time.

I think there are several issues that contribute to a person's trouble choosing to limit aggressive care. One is that America is not a country of "quitters," and this gets twisted by patients and families into "do everything at all costs or you show you are a quitter." I spend a lot of time trying to debunk this one. One is that an oncologist who spends 15 minutes selling chemo, then giving it, then moving on to the next case, er, patient, makes a lot more money than one who spends an hour going over options of just one patient and ends up sending to Hospice, and I do think that influences some docs, unfortunately. I think religion sometimes can be a hindrance for some people, who have the mindset that if they don't "do everything" that they are basically telling God that they don't have enough faith, and thus are setting themselves up for death because they just didn't prove that they believed. Actually, a recent medical study confirmed that "heroics" were much higher in people who considered themselves deeply religious. I think TV is to blame as well; those medical shows that show the good-looking heroic young MD desperately coding the equally good-looking young patient, as if somehow sheer determination could accomplish what a few joules of electricity alone could not, and then the lovely patient wakes up, weak but beautiful, and never brain dead with a tube down the throat, tongue and eyes bulging. I think that
time is an enemy as well; this is delicate stuff to discuss, and just like smoking counseling, I think docs just decide not to waste their breath if a person seems to have a mindset. Lastly, there are some places at which the truth does not exist. I have a person whom I treated for a bad cancer, 9 mos ago, elderly but fit, and a remission with few side effects was obtained for 7 months; a good trade. At relapse, we tried another thing, no response and lots of side effects. I and 2 other docs have said it is time to stop; the person is losing weight fast and getting very weak. Are they going to stop? Nope! They are going to go to "Cancer Miracles of the US," where they will cure anything (says so on TV), at least until the insurance runs out, or when they turn out to be someone who inexplicably can't be cured after all.

There are 2 ethical issues here: The first is that the doc must present all options in a balanced way, and respect a patient's choices (even if the patient wants to have a drawn-out ICU death). The second is that a patient has to make his/her wishes known.

And now I am going to get some sleep from the call weekend.
Print the post Back To Top
No. of Recommendations: 2
So, the doctor wrestled her to the ground, sedated her, did the procedure over her objections, faked her signature on the witnessed consent form and somehow convinced/bribed all the other people on the team (the nurses, the admissions folks, her family) that it was all voluntary on her part ????

Of course not. However, what he did was just as insidious. He pressured her into treatment that she really didn't want. He did this by tapping into her concerns for her husband and his care (what would he do without her) and by downplaying the risks to her daughters, thus enlisting them with the "It'll be okay mom, it's just a little procedure. You'll feel so much better afterwards." Right now, her oldest daughter is feeling a huge amount of guilt because she was the one who encouraged her mom to "hurry up and get it done" sice she had some time off work available and was able to come down to stay with them.

I understand what you're saying about what people hear from the patient is just the patients way to getting reassurance, and I've seen that with my own mom, but believe me, this lady was one straight shooter who wasn't out for reassurances. She was irritated that she'd been talked into a procedure that she didn't really want to do. Heck, when she got her directory photo taken, she insisted that the photographer "un-retouch" the photo so it was an accurate representation:0) She said no one would recognize her without the wrinkles!

I'm not saying that all doctors are this way but around our area at least, we are finding that the accepted treatment option for our ever increasing population of seniors seems to be surgery first.

If she'd had cancer, I could probably see the rush to get her into surgery, but she didn't. She had a small blockage that the doctor seemed to think was minor enough that she was scheduled for day surgery to correct it. It just seems that this was such an unecessary loss of life. She might have died from heart failure in a week, a month or a year, or she might have been hit by a bus the following day, who knows? It just seems that we've hit a point that we don't want to allow someone who has lived a full life to just die of natural causes.

LWW
Print the post Back To Top
No. of Recommendations: 4
If she'd had cancer, I could probably see the rush to get her into surgery, but she didn't. She had a small blockage that the doctor seemed to think was minor enough that she was scheduled for day surgery to correct it. It just seems that this was such an unecessary loss of life. She might have died from heart failure in a week, a month or a year, or she might have been hit by a bus the following day, who knows? It just seems that we've hit a point that we don't want to allow someone who has lived a full life to just die of natural causes.

And she may have lived 20 years more with the procedure. All surgeries have some risk. Some people die from minor procedures. I don't see the doctor did anything wrong.

PSU
Print the post Back To Top
No. of Recommendations: 2
Whatever happened to "do no harm"?

For one, it often conflicts with the "earn no money" problem.

However, in my [limited] experience, it is the patient, or the family of the patient, that demands additional treatment far more often than the doctor strongly encouraging it.
Print the post Back To Top
No. of Recommendations: 1
Thank you, for telling us the other side.

I worked on an old beat up car, it needed a fuel pump, which is pretty easy. And a quick dirt removal and carb tune up, it ran well, the owner was impressed. For about 2 weeks. The bottom end let go, took out some other things with it. While it was a favorite car, it had given it's last service, the decision was to junk it, it had no value, no life left.

And that's the way we are, we want to go on some more, even if all the parts are all worn out. My Mom was like that. She wanted to talk, to hang on, just to know someone was there. I knew for about 3 months it was soon, like next year I lied.
It's almost 1 year. I still remember. The last time I saw her she smiled at me and tried to wave.

We don't call our own time. But we know. People around us know. But you have to look forward and hang on.
Print the post Back To Top
No. of Recommendations: 0
I think a doctor's job should be to help us into this world, to help us through it, and to help us out of it.

--SirTas
Print the post Back To Top
No. of Recommendations: 2
sorry for your friend.....

angioplasty is Usually near to trivial (had two or three myself)
( you could probably google the loss-rate )


So my question:

Why is it that doctors are so hung up on extending life at all costs.


as mentioned below, usually it's the patients, not the doctors.

when it is the Doctor, it can be partly arrogance (this is a trivial procedure), partly legal (if they don't do it, there's a malpractice suit), maybe even sometimes financial (got Ferarri payments to make)

sounds like mostly the first here ..it's ,IMO, one of the problems with our system that the technology has out-paced patients' education so it can be a crap shoot which Dr. you get
( i didn't like my first cardiologist (something to do with Cats) ..so i got another --facing an operation, not everyone feels comfortable with that )


Shouldn't there be some designated age that says if you pass this milestone, then all your treatment becomes optional?

pretty much everything is optional for the patient (the exceptions being when the patient isn't 'competent', or a child --not the case here)



Why do we put our older citizens through all this? Bobbie was prepared to die, she didn't fear it at all. What she did fear was being in pain for no good reason, which is exactly how she ended her days. Whatever happened to "do no harm"?

Doc thought he WAS 'doing no harm' --but Crap Happens. Sounds like your friend had weak kidneys (the procedure stresses the kidneys) and Docs were unaware (hopefully they tested)



/>:
Print the post Back To Top
No. of Recommendations: 4
diana: a thoughtful and excellent explanation of how and why.....

i had uterine cancer in 1990...after surgery EVERYONE wanted me to
do chemo: my doc, my kids, my lawyer...etc....i refused for a variety of reasons...the main reason being that i had asked the doc what my
chances of survival were if i did the chemo....he said 50%...to me
that meant that meant that i only had 50% of survival either way...
so why bother????? my kids laid guilt trips on me: dont you want to
live long enough to see your first grandchild?

ps: i survived, and was virtually free of cancer 'til 2004.....
when a spot was discovered on a lung, and the lung removed. the doc
said it was encapsulated, you dont need any other treatment, go on
your way.

i was lucky---still, 50% was not good enough odds for me to cave in.

patients really DO have the last word.....

yrs,
sasha
Print the post Back To Top
No. of Recommendations: 0
( you could probably google the loss-rate )

"As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty."
http://www.nhlbi.nih.gov/health/dci/Diseases/Angioplasty/Ang...

I'm surprised it is this low. People getting angioplasty are not the healthiest people in the group.
Print the post Back To Top
No. of Recommendations: 0
( you could probably google the loss-rate )

"As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty."
http://www.nhlbi.nih.gov/health/dci/Diseases/Angioplasty/Ang......


thanks for looking that up.

i actually would've guessed lower ...



I'm surprised it is this low. People getting angioplasty are not the healthiest people in the group.



though that is definitely true.



=
Print the post Back To Top
No. of Recommendations: 6
LWW, you are engaged in what we refer to in psychology as counterfactual thinking. It is the 'what if' thinking that people often do when faced with an unfortunate outcome from on a decision that was made (at the time) with the best information available.

"What if she'd not been told to have this surgery? Well, she'd be alive today!" Actually, you can't know she'd be alive today. That 'small blockage' might have resulted in a stroke or heart attack that killed her at exactly the same moment that she died from the surgery complications. And, if that had happened (she had not taken the surgery option and died due to the stroke or heart attack) then you would (probably, because most of us do this when faced with these circumstances) engage in the counterfactual thinking of "Why didn't she take the surgery? She'd be alive today..." etc.

She made the best decision she could. You can claim to know what their conversation was in the doctor's office (I agree with OncQueen who said that people often say things like your friend in order to get encouragement to face the difficult process that was chosen). But, the fact of the matter is you do not know what was said to her, you do not know that there was the 'insidious' coercion. She may have been relating what was going on in her own head and put the words in the doctor's mouth.

Sometimes, you have to trust that people are doing the best they can in difficult circumstances and sometimes it doesn't work out very well... and that there is no actual fault, that there was no ethical misstep.
Print the post Back To Top
Advertisement