Back in action

OK, so after a LONG hiatus (well, 15 months to be exact), I return to the limelight. Not easy juggling this doctor/dad/writer thing. But that's too boring for a blog. So let me share something more interesting:

My patient today, who had no idea why his primary care physician sent him to me when he introduced himself, but who suffers from anemia, black stools and fatigue, revealed, somewhere near the end of his visit, that he wishes to be utterly left alone by doctors. He is 85, and I must confess that I don't blame the guy. The confession was actually the response to a line of leading questions, as I asked him if he was tired of doctors "poking and prodding" his body, to which he nodded emphatically, and finally made his confession. So why did I ask? The truth is, at some point in each of your lives, you might make the same decision. Whether you are conscious, elderly and able to voice this as astutely as my World War I Veteran did, or intubated in an intensive care unit, some small piece of your brain may decide that you've simply had enough. I asked because I felt that this man had had enough. He was telling me that with his body language and with his eyes.


In August, 2009, Alaska Governor Sarah Palin decided to create the term "Death Panel" in response to President Obama's proposal to fund physician visits with patients whose main purpose would be discussing end of life care. Such visits were meant to generate living wills, or documents whose purpose was to state clearly a patient's preferences for how their body would be treated should they no longer have the ability to clearly make decisions for themselves. It was a brilliant proposal. Finally some true forethought would be supported by all of those insurance dollars, and the decisions made in those visits would empower patients who sooner or later would lose the ability to be empowered. The decisions would also save boat loads of money. Most Americans have heard, in the past few years, that end of life care accounts for much of our health care dollars. This article says it best: http://www.newsweek.com/2009/09/11/the-case-for-killing-granny.html . Upwards of 20+ percent of our total health bill is spent in the last 2 weeks of life. And usually these last 2 weeks are only that long because living wills are NOT in place to protect the body from decaying in an ICU, on a mechanical ventilator. Not to say that all mechanical ventilation is a waste, but think hard about whether every death is a tragedy. Would my 85 year old really look good on a vent? Or would he be better off dying at home with a hospice nurse making him comfortable?

Your answer may seem obvious to you. You may say: "Of course I don't want the slow death! Unplug me!" But despite this, it would astound most people to see the decisions their families make when they are actually lying there, ventillated by a machine. Without the living will, someone ultimately lays on a guilt trip and someone else buys in, and suddenly 2 weeks have gone by, just like that. I used to call this "splitting" and families who split were a headache. I had to consciously not side with those in favor of discontinuing care and think hard about the fact that this was someone's mother, aunt, cousin, or friend on the table before me. Still, it was hard. Inevitably, every doctor becomes infuriated by situation which were easily salvageable by a legal living will, had the patient only thought ahead.

So then some of the skeptics out there may ask: Did I lead him into his decision not to have a colonoscopy and work up what could be a cancer? Did my own bias and opinion set the tone that ultimately decided on no intervention? I'd be a fool to say "no way." So instead I'll simply say that when I gave my 85 year old friend a pat on the back today as I said goodbye and added, "don't let anyone make your decisions for you," he turned to me. He looked at me with the kindest, most grateful eyes and said: "You listened."

Decisions, decisions..... these are what we should be making for ourselves as long as we possibly can.