Prolonging Living or Prolonging Dying?

teriwtt
Mon, 08 Aug 2016 18:24:04 +0000

but I think that doctors and medical providers need to be better at telling patients the truth about what the treatments can and can’t do for them, how long it can extend life and so forth, so better decisions are made about hospice care and about perhaps accepting that anything done at the current point would lead to being alive longer but perhaps not the way they would wish to live, and making what time is left as comfortable as possible.

But this is what I was saying… we can do this, but people need to be aware that health care can be an art as much as a science. I can’t tell you how many times in my eight years working in hospice, we admitted patients with dementia to our service, only to have them stabilize then kicked off of hospice services (same could be said with a few other diseases). What happens is there’s a medical crisis with a patient, patient or family decides not to pursue the aggressive treatment and put the patient on hospice, but somehow they stabilize and the hospice staff cannot re-certify them at the end of their certification period when they can no longer document a decline, and they are taken off of hospice services.

As an example (I saw this a number of times) - person comes onto hospice (which means, some physician has certified that, given the normal trajectory of their disease, they will die within six months) with dementia. Yet, two years later (I’ve seen three), they are still alive. What typically happens in these situations is that the patient is now being overseen by a health care team on a regular basis (1-3 visits per week) and steps are put in place that allow that persons to stabilize (as opposed to decline) at some point, and the team can’t ethically (and legally) re-certify them based on a decline, because they are not declining. Maybe it’s because the person is now getting appropriate pain and anxiety medication, so their appetite increases, they’re sleeping better because of decreased pain, so their energy increases. Because their pain and anxiety are better managed, they become a bit more participatory in social life. All these add up to a reality that the person is going to live a lot longer than six months - all this without involving ‘life support’. These kinds of examples are, I think, mostly responsible for why there is a big move these days to also utilize palliative services with some people as opposed to hospice services. It is up to a person’s physician, in consultation with a palliative care or hospice agency, to determine whether they are appropriate for palliative care or hospice care. Lots and lots and lots of gray in the area of end-of-life management. Throw in a loved one who is VERY vocal, demanding, and unwilling to listen to wisdom from health care providers, and you’ve got someone who is steering their loved one’s health care wishes, maybe against what is in a living will.

I’ve thrown out a number of scenarios here to illustrate the unending number of variables that can play in making these decisions and you can see how unrealistic it can be to make such pronouncements (no heroic measures taken) in times of stress. Yes, in some cases, it’s obvious, but walk through any skilled nursing care facility and you’d be amaze at how many more people are slowly dying of dementia as opposed to people who may or may not be in a facility who are clear-cut end-of-life cases (i.e., stage-4 cancer with multiple organ failure, ALS, brain-death such as Jahi MacMath). I just can’t emphasize how many variables there can be, intertwined with the personalities of any given health care provider and patient or loved one making decisions. It’s just not always so neat and clean.