11th hour

Ms. P is 87 years old, on a ventilator and nodding to me to come closer. She points to her throat which is sore and I nod "I know, Ms. P- that machine isn't pleasant." Yesterday, on a pad she wrote to me that she is doing this for her children and her grandchildren. By "this" she means living. She has a terminal lung condition called pulmonary fibrosis and it has progressed to the point of difficulty breathing requiring transplant for which she is too old and frail or a ventilator or option C, hospice and death. She voluntarily chose the breathing machine even though it went against her own belief that life isn't worth living if you can't enjoy it. (She wrote that on her pad a few days ago as well.)

If you missed it, this week, one of the boldest, wisest, kindest and downright most intelligent things ever offered by a president was shot down by a nation in fear. Our president proposed that Medicare pay for end of life counseling visits with the elderly and, hopefully, their families. This reimbursed visit would set the guidelines for a living will and let the patient and their family discuss options for the last days of life. Studies (many of them) have shown that such conversations are not only well received, but makes for a better death both for the patient and their families. This article sums up one such study: http://www.msnbc.msn.com/id/32463644/ns/health-health_care/

Within days of the proposal, conservatives, insurance companies and the PR firms hired by both began a slur campaign against the end of life counseling visits. Ex-governor Sarah Palin dubbed the term "death panels" and within 2 weeks the proposal was stricken from the health care bill. Here, ex-insurance executive Wendell Potter speaks out in his commentary on the role of insurance companies in this PR nightmare: http://www.cnn.com/2009/POLITICS/08/17/potter.health.insurance/index.html

Now I'd like to give a doctor's perspective on this situation, and I dedicate this to Ms. P and her ventilator:

We are a nation terrified of death. We lose our parents at ages 85 and think it's a tragedy. We lose our great grandparents and think they should have lived longer. The truth is, people die. They die at age 1, 12, 31, 51, 72, 102. They die every day. They die in accidents, and from illness. They die good deaths and get to say goodbye and they die quickly and do not. I am quite sure that death is as ultimate as anything. I have seen corpses on a fairly regular basis in my career. And in doing so, something amazing happened: I got over my fear of death. Call it an understanding of nature, or just an appreciation that what makes life valuable is the absolute certainty of its end. But why are so many of us petrified of dying? Are our lives so important that we want to be immune from the inevitable? As a young man, this is so. It is unnatural and unexpected for the young to die. And it is indeed tragic as it rare for a young person to die and often others get left behind for a lifetime of grief. To argue that one should just "get over" the death of a young person would be silly.

But what about Ms. P? 87 years- is that enough? She thinks so. But she never had a Medicare sponsored visit to the doctor- who is trained in not only the facts and procedures, but HOW to discuss this issue. I took classes on the subject in medical school, worked with mock patients to sharpen every skill (and they were all criticized at one time or another) from tone to facial expressions to listening well. This is tough stuff- and we need professionals to deliver the meat of the conversation, and to listen and translate what people are feeling into a plan. A plan that, perhaps, would have saved Ms. P from her horrible, prolonged, painful death on a ventilator.

For what it's worth, her family only visited once in 3 weeks. And I was there when her daughter squeezed her hand and told her to "hang on." And to her I ask: What for?