Death and Dying
Mon April 14, 2014
End of Life Decisions for the ‘Oldest Old’
The “oldest old”, those 85 and over, are America’s fastest growing age group. The growth rate for that segment is four times that of the total population.
People with relatives in that age group or those who have reached that point themselves, may be familiar with the options for aggressive treatment modern medicine offers, options that weren’t available when the previous generations of elderly approached the end.
To intervene or not
Dr. Elizabeth Rabkin, an internist and palliative care specialist with the University of Cincinnati physicians, says doctors, “have a little bit of a problem with accepting dying as a natural part of life.” She says it can be hard for specialists who can fix conditions that used to mean imminent death, to recognize the wearing out of the human body.
“One small thing that might be correctable in a younger person will become like an avalanche and start a process that is unfixable,” Rabkin says.
Dr. Gaurang Gandhi is an intervention cardiologist with the Tri Health group in Montgomery. He installs pacemakers and defibrillators.
“When I came out of my fellowship I wanted to go fix everybody in the world and I thought I could fix everybody. Now I understand there are some limitations in what I can do and achieve,” Gandhi says.
“…We’ve become conditioned to just do things to people, not necessarily for people or for their benefit, says Dr. Bechhold. [Patients] “end up with a long phase of dying that sometimes is very uncomfortable. It can be painful, it can be emotionally devastating, it can be financially devastating.”
Elderly people are often confronted with a serious or terminal condition a specialist is ready to fix.
When her 85 year-old-mother was diagnosed with ovarian cancer, Susan Brogden of Harrison faced a doctor anxious to offer aggressive treatment. The oncologist suggested surgery and chemotherapy, to extend her mother’s life by several months.
“Frankly I assumed that treatment would not be suggested given her age and given the stage that the cancer had advanced to”, Brogden says.
Brogden says she, her sisters, and her mother questioned the wisdom of treating the cancer even though the doctor was optimistic.
“We simply felt that it was non-sensical. That there is no such thing as surgery at any age, especially 85, that pretty much doesn’t suck everything you’ve got out of you and that chemotherapy would be just brutal for her. She felt that way, we felt that way. It would have gained nearly nothing in terms of remaining life for her.”
Brogden’s mother declined treatment and died three months later.
Making the choice
Dr. Rabkin understands the concern of those who question the value of aggressive treatment of very old patients.
“… People get sort of talked into things or their arms twisted because they’re not strong enough to stand up to somebody who’s very dogmatic about pushing a certain treatment. But she adds, some interventions for a sick and elderly patient are worthwhile."
“I always tell the patient that no intervention is off the table if it’s going to help you meet certain goals…if it’s going to help relieve their pain or discomfort, or if it’s going to help them get back to their home.”
When contemplating a procedure on an elderly patient Dr. Gandhi thinks about his parents. “Would I do this to my mother or my father and if the answer comes up ‘yes’ then I’ll do it…If the answer comes up ‘no’ I will not do that procedure.”
Gandhi said his father had a heart valve replaced at age 82 and lived another 13 years. He said his father would have lived to be 100 if he had had a defibrillator installed, but “that was not his wish”.
Weighing the pros and cons
Dr. Gandhi says sometimes the answer to the question about the value of an intervention is unclear. Gandhi and other physicians say they try their best to help patients understand their choices, the pros and cons of life extending treatment. But that conversation, Gandhi says, takes more time than many doctors have.
“To refrain somebody from getting a procedure that is indicated but is not the right procedure for the patient because of the age, quality of life they’re having and the expected life span and to not do that procedure takes a lot longer that to do the procedure itself.
Helping patients understand their prognosis, Rabkin says, is an important part of a doctor’s work.
“We have the responsibility to say to the patients ‘I wish that this intervention would be helpful for you but it’s not necessarily going to be helpful so I would advise against it’”
The temptation to fight
Bechhold says its not just doctors who want to do something. Patients often do too.
“We’re always told we have to have a good attitude, you have to be positive you have to be strong, you have to be a warrior, you have to fight this. So they end up fighting something that they had no chance of beating and they suffered side effects while they were trying to beat the illness,” Bechhold says.
Doctors say patients’ children often push for aggressive treatments.
“You have families who say ‘but mom you’ve always been a fighter. You have to do this’”, says Bechhold. “…We’re talking about people sometimes in their eighties and nineties where the children are still saying ‘but you have to do this for me, you can’t give up, you can’t not take this treatment."
Susan Brogden and her family, however, “never had a minute’s regret” that her mother chose not to have aggressive treatment.
Accepting the inevitable
82-year-old Isabelle Stamler, who taught in the Wyoming schools for many years, faced a similar choice when she was diagnosed recently with liver cancer.
“I discussed with my son who is a physician what my alternatives were and he said I didn’t have many, “ says Mrs. Stamler. “So I just determined to make my life as comfortable and as normal as I could make it for what time is left to me. "
Mrs. Stamler, chose not to have aggressive treatment. She lives in a retirement community in Wyoming.
“I have a lovely little home. I have friends. I have very much going on for me. I’m not ready to give that up for trinkets and I don’t even know if people get trinkets out of it.
Some elderly patients do choose to fight to the end. But doctors say when they’re able to explain the benefits and burdens of a life extending treatment, patients often react as Mrs. Stamler did, choosing a peaceful end rather than enduring treatment that might add only very uncomfortable weeks or months to their lives.