Let me tell my readers a true story. A person I know, who is 89 and has a number of significant chronic diseases (none of them “terminal”), has been admitted to the hospital each month for the past nine months. Her stays in the hospital vary from overnight to a few days, and are mostly for dehydration, infections of the lungs or urinary tract, intractable constipation, and uncontrolled blood pressure. She is on a total of 15 medications, cannot leave her home, and is in chronic pain. Her days at home are spent in bed, sometimes watching TV, reading or doing the crossword puzzle.
Now, when my editor presented me with a recent article by Paula Span in The New York Times about a surgeon in Denver who does not operate on patients who are overly frail and elderly, it really hit home. In fact, it jogged my memory about a surgical case I was involved with two decades ago. A 90-year-old nursing home patient who was bed-ridden fell out of bed and broke his hip. He came to the operating room for a “hip pinning,” where the broken bones are put roughly back in place. He was all twisted up like a pretzel, moaning in pain, and with no intelligible speech. The poor man was in agony. I kept asking myself “why are we doing this case?” As I was giving the spinal anesthetic, I wondered whether we physicians were really doing this unfortunate man a disservice by prolonging a life that, for all appearances, was rife with pain and suffering. It was hard for me to imagine this man, who had lived a full life, looking forward to anything. My thought was to just treat his pain and make him as comfortable as possible, which is quite different than euthanasia. Doctors should not euthanize but rather comfort and support during the process of illness and death. No “active” ending of life is appropriate, in my opinion, as is no artificial prolongation of life when the hopes of any quality of life is absent.
The article is a challenge to the belief that we must, as a society, generally treat patients medically and surgically at all costs, despite how old, sick or poor their quality of life. Certainly, there are exceptions to this tenet, but for the most part Americans believe that our far-advanced medical care, with its life-prolonging and life-saving qualities, is to be wielded whenever and wherever an insistent family member or loved one dictates. Indeed, family members often clash when an elderly parent is chronically and seriously ill, only to be saved by heroic, advanced medical care. Further complicating the issue is money; the cost of continuing care, as well as the often substantial estates that many elderly possess, are two major issues that divide families near the end of a parent’s or other relative’s life.
Many questions emerge here. One is, where have we come in terms of life span? You’d be shocked to learn. In 1900, the average white man lived 47 years…a white woman, 49. The average numbers for blacks were worse: 33 for men and 34 for women. By 1960, the numbers across the board had improved to averages of 67 for white men, 74 for white women and 61 and 66 for black men and women, respectively. Today, the averages are up by a decade to a decade and change. Clearly, the things that killed people at a younger age in 1900 and 1960, like infectious disease, cancer, cardiovascular disease and childbirth, are being medically mitigated and in some cases vanquished.
Another question concerns quality of life. We all know what that is: the ability to enjoy, participate in, look forward to or otherwise value existence, both in health and during chronic illness. Certainly, medical and surgical care in our country has enabled this to occur. Medications, surgical techniques and other groundbreaking therapies (stem cells, radiation, gene therapy, etc.) have enabled many to live longer and, in some cases, better lives. I say “some cases” because of the example I began my article with: a person pushing 90 on a number of expensive and side-effect-inducing medications who is in and out of the hospital, and who is really clinging to life. I have no doubt the person in question would flunk the Denver surgeon’s frailty test mentioned in The New York Times article.
Where does this sentiment, i.e. the justification of the restriction of some forms of medical and surgical care, leave us as a society? The question is complicated and will only get more complicated. In my many blogs, I have written about the importance of lifestyle changes, the contribution of obesity to poor health, the ever-growing number of medications and supplements patients take, the rising colorectal cancer rates in younger people and the alarming increase in opioid dependence and overdose deaths. These factors, among others, are the recipe for the following scenario: a culture where people are on more medication, with more frail elderly and people living extended, but not necessarily better, lives.
I have no doubt life span will continue to rise. I also have no doubt that these longer lives will be burdened by chronic disease. I base this conclusion on the shocking statistic that nearly 70 % of Americans are overweight or obese, with that trend not ending anytime soon. In a prior blog, I called this problem “the mother of all diseases”. I still contend that this alone will lead to an economic stress severe enough to compel the forces that dictate the cost, allocation and availability of health care in the United States to make these hard choices about who will get treatment for certain diseases and who will not.
Simply put, the status quo is not sustainable. As I’ve said many times, we do not merely have a “healthcare crisis” in our country. We, more importantly, have a “health crisis.” But no one seems to want to talk about that. Until we do discuss this, openly and frankly, and implement some of the measures I alluded to in a prior blog about the obesity problem and substance abuse, the decision over whether to treat the too frail or too chronically sick will answer itself. After all, money still talks and makes the world go round—the economic factor, not medical ethics, not the judicial system, will be THE deciding factor regarding this thorny issue.