A first look at end of life issues

We have to die eventually, a fact of which we are all sufficiently aware; yet we rarely, if ever, think about how it might unfold and we certainly don’t talk about it. The lack of discussion as individuals and as a society about end of life issues adds to emotional distress and to increasing health care costs.

Imagine Grandpa of one hundred years of age whose heart has stopped. Miraculously the event is witnessed, he is resuscitated, pacemaker pads are quickly placed on his chest to keep him alive, and he is rushed to the hospital. On arrival he is in critical condition and sedated on a mechanical ventilator, and he is transferred to the intensive care unit. Grandpa can’t communicate his wishes, but if he is to survive long-term he will need an implantable pacemaker. Do we place the pacemaker?

You, as the next of kin, are now in charge of the decisions regarding Grandpa’s care. Unfortunately, Grandpa never discussed his wishes with you about what he would want done in these circumstances and never drafted a living will. Faced with the life and death decision, determining the fate of Grandpa, the decision seems clear: uphold life above all else and place the pacemaker. However, is that the best decision?

For the last five years he has suffered from worsening Alzheimer’s dementia. He no longer knows who he is or where he is. He spends his days confused, and someone feeds him, changes his diapers, and turns him so he doesn’t develop bedsores. Do we still place the pacemaker?

Are we doing Grandpa a service by placing it? He has lived a good number of years, more than many of us can dream of, and at one hundred years of age one day in the near future, whether a pacemaker is placed or not, he will likely pass on. What if he believed that he had had a great life, that his wife, friends, and neighbors had already passed and that he would one day pass from something?

Remember Grandpa already died once. His heart stopped. Modern technology merely brought him back to life, and only for this reason are we faced with these questions. His mental function and lifestyle prior to the cardiac arrest were poor, but as a result of the cardiac arrest and resuscitation efforts his mental function will likely be even worse, if he is not already neurologically devastated.

You finally decide to not place a pacemaker and, in so doing, believe that you are fulfilling what Grandpa would’ve wanted. You then discover that your younger brother Jimmy, who only now has arrived at the hospital, disagrees with you and the rest of the family and believes Grandpa would’ve wanted the pacemaker. A family debate ensues. Without truly knowing Grandpa’s wishes there is no right or wrong answer. How does the family resolve this issue? How do the doctors resolve this issue? You as the next of kin are legally empowered with making the decision, but for obvious reasons doctors, like families, prefer unanimity in these situations.

Meanwhile days pass with Grandpa still in the intensive care unit lying in bed, staring at the ceiling unresponsive, and awaiting a decision. The doctors pepper you with other questions. What would you like done if Grandpa were to go into cardiac arrest in the hospital? Would you want him to receive an electrical shock in attempts to disrupt an abnormal rhythm and rescue him? Would you want for him to again undergo chest compressions (in which, yes, if done properly ribs are cracked) in attempts to maintain circulation as he is resuscitated? Would you want a tube placed in his stomach to feed him as he is no longer able to eat on his own? Would you want to continue drawing daily blood tests?

Is this how Grandpa imagined passing away? What if instead for the last five years rather than dementia he merely suffered from severe arthritic pain that confined him to a wheelchair and about which he complained incessantly? What if instead he had been a healthy one hundred year old man? Lots of questions arise.

The lack of discussion as a society of end of life issues (hoping instead for others to address or for the issues to go away) negatively impacts us and (to be addressed further) also leads to higher health care costs and to a skewed distribution of society’s health care expenditures.