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End of Life Health Care

End of Life Health Care

The new geriatric physician entered mother’s nursing home room and asked her, “What do you want me to do for you?’ Louise B. Raggio, a formidable woman who had hung on for years after undergoing chemotherapy, replied from her bed: “I want you to make me well.” Dr. Sledge responded: “What if I can’t do that, what do you want me to do?” Mom’s answer was immediate: “Bury me.” She died within a month.

Her husband, Grier H. Raggio, had passed years before in his own no-nonsense way. At 75 years old, Dad’s heart was 80% dead. There was no coming back, and Dad was disgusted with his shadow life and the difficulty of every small exertion. One day he asked a son to drive him to his law office; once there Dad opened a drawer where he kept a loaded pistol. My brother, who knew his father had been a migrant worker-hobo in his teens, a war veteran and a fighter,  had hidden the pistol. A week later Dad died at home, peacefully, in his bed.

A long article by Michael Wolff in this morning’s Dallas Morning News titled “The length of time it can take to die is one of the great horrors of modern times” renewed my commitment to let go gracefully when the time comes. Modern medicine is able to keep the shells of what were once active, vibrant people alive for years, but why? Wolff speaks from his own mother’s long years of being kept technically alive: “Make no mistake, the purpose of long-term care insurance is to help finance some of the greatest misery and suffering human beings have yet devised.”

America, and every other society, has finite resources. Health care in the United States consumes about 18% of the gross national product, twice as much per capita as some other Western countries which have better overall health results. Much of  that goes for heroic medical care for unfortunates, like Wolff’s mother, who have no reasonable chance of returning to a full life. Even though we consume more health care than any other country, we still ration health care; we just do it chaotically and unfairly.  Other countries’ systems would not have supported  using resources for major heart surgery on Wolff’s 84-yer-old mother, who was “showing progressive signs of dementia.” We did.  Insurance paid the $250,000 bill, the heart was repaired, and she returned much diminished to a deepened shadow life while numerous children from poor families continued to go without adequate medical care.

As with other big issues, politics often vetoes rational, humane cost-benefit analysis in health care. Demagogues attack “rationing” health care as “death panels” and “killing grandma.” Legislators get spooked, and thoughts of the “common good” are buried  with the rest of the hazardous political waste. Meanwhile we watch a system that consumes too much careen towards bankruptcy, speeded by science’s ever-growing ability to keep people technically alive, in whatever deteriorated condition.  On the positive side, today’s New York Times has two pieces, “Treating You Better for Less” and “Let’s (Not) Get Physicals,” which describe several “successful experiments” which “reduce the cost of delivering medical services while maintaining or improving quality” for all of us.

Image by Blogotron (Own work) [CC0], via Wikimedia Commons

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Comments (7)

  1. Charlie Sledge Monday - 04 / 06 / 2012
    Grier, right on point! Thank you. I hope you recieve many responses. I would love to see, on balance, the pros & cons on this topic. End of life care is done well by too few in my opinion.
  2. Randall Espinoza, MD, MPH Monday - 04 / 06 / 2012
    Grier, this conversation is a very necessary one but fraught with pitfalls. The value of human life across the years cannot be rationally rationed. However, it can be valued differently and differentially ala actuarial tables, and often is. Notwithstanding, continuing to pit older groups against younger groups, or rich groups against impoverished ones, is not equal and certainly not fair, if only for the inexorable movement and variable of time and its interaction with biology, socioeconomics and ecology. Infants, children and adolescents with brain or other serious physical injury are no more likely to benefit from aggressive care, or benefit society, than an older person. What is often different is what was contributed by which group over the decades of life and living, and here, older persons have often been very productive. Other countries with better health outcomes also allocate or count costs and charges differently. We do so by taxes, so things quickly get deceptively simple when comparisons are being made. Most other countries talk about population approaches and favor prevention programs, we do not. It costs less to prevent a future problem. Ironically, these other countries have older and aging populations! Alas, to be completely fair, even in these supposed paradigms of optimum consumption vis a vis healthcare, rates of ageism are high. To be old in Scandinavia or Northern Europe is not any better than here in the USA . We consume too much and care too little.
  3. Elisa Reiter Wednesday - 06 / 06 / 2012 Mr. Wolfe's article was originally published in the May 28th, 2012 issue of New York Magazine, and brings both smiles and tears. Technological advances are sometimes not a blessing, when one is struggling with the ethical dilemmas posed of assisting a loved one. The issue strikes close to home for all -- or will. Thanks for sharing Grier -- Mama Louise and Papa Grier are to be admired -- and they would be very proud of your observations.
  4. victoria Wednesday - 06 / 06 / 2012
    Grier, I have a slightly different perspective, a recognition that needs are changing, the individual is taking more personal responsibility and power of choice in terms of care and treatment (and death and dying) . With evidence of a more balanced approach between great technological advances and old eastern methodologies, I am convinced that new kinds of resources can and will be developed to meet real needs. My Mom is a highly functioning 102 year old who is looking forward to celebrating her 103rd birthday, July 20. When you refer to 84, you seem to think there is something automatically "old" about that number. Look around you. There is a growing circle of individuals who are aging quite well, thank you. The luckiest among us are Blessed with generally good health, but many have also chosen good habits, exercise and nutrition and perhaps meditation, yoga, or energy practices which reduce stress and keep the body/mind clear and strong. Almost all who move seamlessly across the decades into this "sphere of freedom" are engaged fully in issues or projects of challenge and dimension. The healthiest seem to stay away from regular medical intervention and prescription drugs, focusing on prevention. And relationships with friends and family are intrinsically important to a sustainable state of wellness. There are many factors involved in an aging society, but it serves no useful purpose to rhetorically pit old against young for resources. Clinging to a sense of lack can only produce what is expected. Creativity among human beings depends on those whose outlook is less despairing and who are equipped to engage in risk. Your Mom was a natural. Victoria
  5. Rabbi Mark Winer Thursday - 07 / 06 / 2012
    In my mother's last year she was dying from pancreatic cancer. It was non-stop misery. The powerhouse woman who had been central in the lives of so many, was racked by pain continually. Nightly I prayed with her over the telephone, her in Dallas, me in London. Every night I prayed with her to God, that the Almighty might allow her to die in peace and dignity. In my last visit to her bedside in Dallas, I begged her physician, with her full agreement and in her presence, to give her medication to allow her body to "slip off into the night." I told him that as a rabbi in England, I had witnessed many similar end-of-life situations among my congregants. It was accepted British medical practice to give the right combination of drugs to allow nature to take its course. British doctors did not consider such treatment "euthanasia." British doctors were "treating pain." He responded that in Texas the law would not allow him to do such a thing. I did not give in. I told the doctor a classic story from the Jewish tradition of a learned sage who had lived a long, productive life, but was terminally ill. He had recited his traditional Jewish confessional prayer on the deathbed Surrounded by his disciples, they were all praying for God to let him die and welcome him into the "Yeshiva Shel Maaleh" - the "academy on high.". But, according to this traditional story, he would not, simply could not die. Suddenly, one of his disciples realised the problem. A woodcutter was chopping wood nearby. The noise of his axe striking the wood was rhythmic, chop, chop, chop. With the consent of the sage and all of his disciples, the student went outside to ask the woodcutter to take a break in his labour. He did so immediately, and the ancient rabbi died in peace and dignity. The doctor was visibly moved by the story, but apologised that he could not do such a thing medically. Later that afternoon I left for DFW to return to London. As the taxi was pulling away, my mother came out feebly to waive "goodbye.". I sobbed, knowing that I would never see her alive again. We continued our telephone daily prayers for death, but her suffering only increased. After a couple of nightmarish months that seemed like eternity, Mom's and my prayers were finally answered.
  6. George Draper Thursday - 07 / 06 / 2012
    Good, thought-provoking article, Grier, and Dr. Spinoza's answer equally so. Given the culture and politics of the U.S., it seems to me vital that all geezers make clear to families and physicians, in writing, exactly what end-of-life preferences we have. A variety of tools for doing so exist, on-line if not at our PCP's office. Beyond that, it's a crapshoot, like most things in life. You were lucky with your parents, as I was with mine: their deaths were relatively quick and peaceful. Dementia is the real bugaboo, and it does little good to reserve the right to take yourself out -- a solution easier said than done. What, you think there was no dementia in Epicurus' time? He may have died a blithering idiot, for all we know. Or been inspired by Socrates' way out.
  7. Nancy L. Ruder Saturday - 09 / 06 / 2012
    My dad got tangled in a vine while checking his rain gauge, fell, and broke his hip. The August sun was blazing down. I often wonder what his choice would have been if he could have seen his future. Would he want to be discovered by a neighbor or not? Would Dad have wanted his next six years of life? Those years would start with hallucinations after surgery, escalating dementia, a second hip break and many falls and injuries. He would be house-bound, often confused or panicked, yelling at the t.v. and at the aides sent to "help" him, obsessed with time but unable to "tell time". Would Dad want to be wheelchair-bound, unable to read or count, completely incontinent, and warehoused in "skilled care facilities" with loud, violent roommates? Dad would be unable to distinguish between the phone, the t.v. remote, and the nursing call button, but the staff would be unable to discern that all of those were either unplugged or malfunctioning. The staff wouldn't notice his painful bladder infections either, but would note if he did not go to bingo. Would Dad, the retired structural engineer, want to be unable to use his hands to write, draw, or feed himself, and to be past talking except for rare clear outbursts of swearing at the hospice pastor? Would he choose to spend months bed-bound, staring up at a warped suspended ceiling, unable to feed himself, to chew or swallow, but ripping out his oxygen tube? If Dad had fallen on the other side of the honeysuckle vine the neighbor wouldn't have seen him. Dad would have exited with dignity and self respect, good friends, a clear sense of being loved by his family, and his wonderful wisdom and sense of humor in tact. How can we learn to recognize and respect exit events as adult children, physicians, care-givers, and yikes, politicians? Could end-of-life decisions be made out of compassion unimpeded by pharmaceutical and insurance economics? We all have different time tables. I respect the comments from readers with 102 year old parents, but even with excellent nutrition, exercise, and habits we won't live forever. And we shouldn't be forced to do so just because medicine has the ability. Thank you for your link to Wollf's article and for your thoughtful post.

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