No Dying Allowed

Not while the insurance holds out

In a recent press release, a leading member of a team studying heart surgery in the US said, "We're doing bypass surgery on 85 year old patients." A good bet is that there aren't a lot of those operations being performed right now in Uganda or Iraq.

A world-renowned expert in EECP, a treatment for heart failure and angina, indicated that more and more elderly patients are candidates for this life-extending procedure.

So what happens after this now almost routine maintenance? Patient jumps in the car and drives out into rush hour freeway traffic? Goes back to the retirement home to watch TV? Actually, there are rules in place to determine "quality of life benefit" before performing heroic medical feats on elderly people, but just a few. The main predictors that a procedure will be done are its availability and a good health insurance policy.

With technology now at a stage where almost anybody's heart can be preserved and kept beating (pacemaker), protected from dangerous rhythms (implantable defibrillator). or replaced with a spare (transplant or mechanical heart) we should be engaged in 24 hour a day discussions of, "What the heck are we doing and why?"

Actually, deep within the innards of somebody's think tank, committees on ethical behavior are tossing the question around. They're probably tossing it like a really hot potato, since the main issue is the value of a life in which dementia may be lurking around the corner or already starting to take hold.

It's a two part question: 1. What's the risk that we're operating on someone who is now or soon will be not quite right in the head?, and 2. Who decides?

If you weren't depressed before you started reading this, there is some risk you will be when you finish. On the other hand, avoiding the issue doesn't really work well. What has to be done is for us all to devise a list of "early" advance directives to be put in place long before the easy instructions about life in a vegetative state become operative. (The easy ones are those which can be made by a person's designated power of attorney based on easily observed and interpreted evidence.)

Decisions based on what might happen in a year or two, or those based on economic factors have to be made by the patient involved, who is, logically, strongly influenced by the opinions of his chosen medical experts. These decisions are not always made with careful evaluation of all possible outcomes, since there may be a climate of urgency involved. Adding to the urgency is the often used comment, "Well, I'm afraid you're just going to die (in a week, a month, a year) if we don't do ---."

Oh, and like Columbo, "There's just one more thing", which is family pressure in one direction or the other. If a spouse says, "Do this", and a child says, "Do that", and another says, "Leave me out of it", how can someone reach a good conclusion without alienating one or the other?

When are we going to have a national debate about this? There are a lot of us who care enough to try at least to understand what we're facing, but very few willing to lead the discussion. Any volunteers out there? How is this situation played out in countries with national health plans and decisions influenced by the budget?

It might make you wish for the good old days when the family doctor stood by the bedside and said, "Too bad, there's nothing more I can do. We'll just keep her comfortable as long as possible."

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