What are we Scared of?

Listen carefully-I have an important secret to reveal (we as physicians often hold our medical wizardly very close to the chest so this may be a rare opportunity).  One inescapable fact of life is that ultimately we all die.  It is the final outcome for us and for all our patients.  Of course, neither I nor other physicians need be fatalistic-there is much we can do to help our patients live long, happy and healthy lives BUT we do always have to keep this basic tenet in mind.  It is as basic a medical principle as those of circulation, respiration, and digestion which most second graders have mastered.
So why have we, as Americans in 2010-2011 decided there is some crazy taboo about discussing end of life issues with our patients?  During the recent Health Reform Debate, this topic became politicized as "death panels" (bipartisan debunked by PolitiFact).  Then just last week, the subject was again stirred up by inflammatory headlines such as The Hill's:

Medicare chief: Keep gov't out of end-of-life care planning

By Jason Millman - 02/09/11 12:55 PM ET

I can honestly say that in my many years as a neurosurgeon, I have done more good for my patients through such end of life discussions that I have done with my scalpel. That doesn't mean I have spent my career rationing or withholding care, it doesn't mean I have easily given up on difficult cases, and it certainly doesn't mean I have been lazy (done well, these types of discussions are more time consuming and difficult that alternatives). But it does mean I am honest and realistic, I am willing to broach challenging subjects with my patients and their loved ones, and I have learned to carefully use words such as futile. In doing so, I know that I have helped these people begin the challenging process of grieving in a way that will help them emerge on the other side whole. In doing so, I have gained invaluable inner riches that provide me sustenance.

It is rare that someone feels it is a "right time to die" and no wants to be cheated (for themselves or their loved ones) of a treatment that could allow them to live for a day/week/year/decade. However, I also believe that no one wants to be kept ignorant of critical health decisions or to suffer needlessly because hopeless treatments are administered. On one level, the politicians got it right-we need to take politics out of death-but that doesn't mean we can ignore reality.

Is it a surprise?

Our population is getting older and increasingly, medical decisions are being made in a relative vacuum...what real experience is there for treating 85-90 year olds with breast cancer? how do we manage the couple each over 95 and generally healthy but now with one needing surgery?do we remove brain bleeds in patients over 90? over 95? over 100? How do we guide our decisions? And are the 85+ of today like those few who may have been studies a decade ago? and perhaps more importantly are today's 85+ the same as those that will reach that milestone in the next 1-2 decades the same?
There is so little that is known about this entire issue.  I have been proposing for years that a fortune could be made by the right enterprising person in establishing specialized medical facilities for our "geriatric" population.  I know we now have geriatricians but that doesn't mean we have figured out how to best administer care to this population or how to best manage their multifaceted issues.  Most people I know (personally or professionally) who are over 65 are seeing a minimum of 3 physicians and many are regularly seeing 5 or more (PMD, cardiologist, gynecologist, gastroenterologist, urologist, orthopedic...).  I see a high incidence of depression and as a specialist unrelated to most of the "common" disorders, I sense a complete lack of understanding of (on the patient's part) of the purpose of their medications and (on the doctor's side) or their potential for interaction.
So I was not the slightest bit surprised to see a recent article in the NEJM that demonstrated that coordinated care for medical and psychological issues leads to better outcomes.  The only surprise was that such a study need be done to prove such an obvious concept.  Our health care system is truly challenged and will only become more so with the advancing age of our population-we need to find a new paradigm for treating this group of patients and to better understand the effectiveness (and thus the need) for our interventions.  This must be a rallying cause for 2011!

The best over 90 woman I have ever known-my Grandmother Frieda

Sad, So Sad

She was 78 with bones to thin I could see through them on xray

And a spine so crooked, she could challenge a pretzel

She had seen three world class surgeons who had said "No"

But here she was,hope in her eyes, asking for my help

She was 78 and in pain and her predicament so sad

Her problem was nature and the bad hand it had dealt

And no medicine nor surgery could outwit Mother Nature

So no one wanted to help, it just wasn't their job

She was 78 and her husband even older

No one wanted them to suffer but there was no easy answer

And together they refused to accept and so on they wandered

Wasting resources and time and getting less help than they should

She was 78 and in pain and the system conspired

So that she kept up her futility, remained in great pain

And once again, I shook my head and knew in my heart

She had failed the system and the system failed her.

George Harrison So Sad