The last few weeks have been somewhat difficult for me with the death of my Father.

He would have been 98 if he held out for 7 more weeks. Which brings out some thoughts. How long should we live? When is enough, enough? Oliver Sacks points out that “We have come to medicalize aging, frailty, and death, treating them as if they were just one more clinical problem to overcome. However it is not only medicine that is needed in one’s declining years but life- a life with meaning, a life as rich and full as possible under the circumstances.”

Dr. Atul Gawande’s book Being Mortal is an insightful book regarding the limits of medicine as well as about living to the last with autonomy, dignity, and joy.

What really matters in the end?

I realized some of these important facets over the last few years. It is the quality of life and not the number of years one lives.

My Mother who had three strokes, Parkinson’s disease, and progressive dementia told me in one of her lucid moments that life was no longer tolerable and she wanted to die.

Should we allow patients to determine their ultimate time of demise? A number of states are allowing that to happen within certain restrictions and strict examinations.

My Dad and my brothers and I had the “important conversation” with my Dad about two years ago as his health and especially his mind was starting to deteriorate.

How aggressive do you want us to direct your care and do you want to be resuscitated if you can no longer contribute to the discussion?

I have had this discussion with a number of my cancer patients who are referred to my office for surgery when their medical conditions would not allow me to perform the surgery without severe complications and yes death. It is a difficult conversation but one that needs to be discussed. The patient needs an advocate, even in this often difficult time.

I have asked patients and their families if their doctors have these conversations and the answer is usually no. This is probably why the advanced stage cancer patient ends up in my office.

I remember one ninety seven year old patient that I saw for a consultation for a very large squamous cell carcinoma involving his right cheek and after my exam I could tell that it had already spread to his neck lymph nodes. He also had a pacemaker and cardiac defibrillator, had a stroke and had kidney disease. I tried to explain to his wife that the surgery would most likely kill him and that was if the anesthesia staff allowed him to be put to sleep for the surgery. I suggested after reviewing the facts, that the best option is for her husband to have radiation treatment to reduce the swelling and make things more comfortable for him and enjoy his last few months, also taking advantage of hospice. She was angry and stomped out of the office with her husband. A year and a half later she returned to thank me for the advice and that she was sorry for being so mean to me. She wanted to know why more physicians were not honest with their patients and their families.

I think physicians are uncomfortable with that “important conversation.” We need to look at the ethics involved in these “end of life” conversations and decisions. This is so important as we find more ways to prolong the physical being with immunotherapies, replacements of better body parts, and transplantations of almost every part of the internal “parts.” Again, quality is so much more important than quantity.

Dr. Gawande considered the case of La Crosse, Wisconsin where its elderly residents have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there’s no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year.

It was pointed out that in order to understand La Crosse, you had to go back to 1991, when local medical leaders headed a systematic campaign to get medical people and patients to discuss end-of –life wishes. Within a few years, it became routine for all patients admitted to a hospital, nursing home, or assisted living facility to sit down with someone experienced in these conversations and complete a multiple-choice form that boiled down to four crucial questions. The four questions included are:

1. Do you want to be resuscitated if your heart stops?
2. Do you want aggressive treatments such as intubation and mechanical ventilation?
3. Do you want antibiotics?
4. Do you want tube or intravenous feeding if you can’t eat on your own?

By 1996, 85 percent of La Crosse residents who died had a written advanced directive like this, up from 15 percent, and doctors virtually always knew of the instructions and followed them, which makes the jobs of heads of the ICU and Emergency rooms vastly easier. But it’s not because the specifics are spelled out for the heads of the departments every time a sick person arrives in their units. These things are not always laid out in stone, but whatever the yes/no answers people may put on a piece of paper, one will find nuances and complexities in what they mean. Instead of having the discussion when they get to the ICU or the emergency rooms, many times the discussion has already taken place.

Dr. Gwande points out that the answers to the list of questions change as patients go from entering the hospital for the delivery of a child to entering for complications of Alzheimer’s disease. But looking at the La Crosse case, the system means that people are far more likely to have talked about what they want and what they don’t want before they and their relatives find themselves in the throes of crisis and fear. We find that where wishes are not clear families have also become more receptive to having the discussion. The discussion, not the list, was what mattered most. The discussion had brought the end-of-life costs down in La Crosse down to half the national average.

In my and my parent s’ situation, when the nurses called me with the requests for hospitalization, IV fluids, etc. we had the direction of their care outlined for their comfort and best wishes.

Now we need to also consider the future of our health care system and how we will be caring for our elderly. Remember, one of my major concerns was as to the sustainability of the system.

Look at Social Security and Medicare as the government seems to love balancing budgets by borrowing from these programs. Federal policy toward health insurance exhibited a pattern that was the reverse of Social Security. The incremental health policy measures adopted after World War II- tax benefits for the employed and Medicare for the elderly- blocked a universal public system. National health insurance, after Kennedy and others decided to accept private insurance as a means of achieving universal coverage, had no route forward except to become a program of comprehensive reform, aiming to control costs as well as to expend coverage.

Now with the Affordable Care Act also has and will continue to be an instrument of cost containment and already there is the strategy to cut back on Medicare and revise Social Security.

As pointed out by Betsy McCaughey, PhD and former Governor of New York, did you know that?

• The Obama health law awards bonus points to hospitals that spend the least on seniors.
• Hospitals will be “whacked” with demerits for care that seniors consume up to thirty days after leaving the hospital, including physical therapy.
• Doctors will be paid less to treat seniors than any other patients, even less than Medicaid. And guess what? It is happening already!!

When assessing what the impact of Medicare cuts will be on you and your family, ignore the political rhetoric and look at the scientific evidence. The cuts will doom seniors to more painful aging and shorter lives.

Chief Actuary Foster, on July 13, 2011, warned Congress that seniors will have difficulty finding a doctor to treat them. Even doctors who continue to take Medicare, at the discounted rates of reimbursement for their services, won’t want to spend time doing procedures such as knee replacements when the pay is so low

Will these cuts lead to our restriction of care to our elderly the USA?

They already have!

Before you answer, remember what we have seen in the other countries that have a “socialized medicine” type of health care system.

Are we willing to sacrifice our elderly?

And remember to have that “end-of-life conversation with your parents, spouses and elderly patients.