Scrubbing In: Importance of spelling out last wishes

My 87-year-old patient fell at her nursing home in West Chester and was quite black and blue when she arrived at the Wills Eye Emergency Room. Her eye had borne the brunt of it. Stitches around an old corneal transplant had ripped open as well as those from an old cataract wound. If that didn't get repaired in 24 hours, she risked getting a serious infection.

When I met her, she couldn't answer my questions. All she did was moan and squeeze my hand with a firm grip. Her chart listed dementia as one of her many problems. Her caring daughter, who was at her bedside, told me her mother had been hospitalized recently for over a month with aspiration pneumonia, which occurs in elderly people who cannot swallow properly.

The family had briefly considered putting her in hospice, where patients with short life expectancy can receive pain medicines and other comforts during their final months.

However, her advance directive wasn't entirely clear, and her family couldn't agree. They decided to err on the side of treating her aggressively for all of her ailments.

The surgery we planned costs about $900, according to Medicare billing, which would pay for her care.

The hospital stay and operating room are separate charges that likely would triple or quadruple that bill. It's not the most expensive procedure, but not cheap either.

In the preoperative suite, the anesthesiology team, the senior ophthalmologic surgeon, the residents and the nurses discussed her case heatedly before it was scheduled to go. "We're between a rock and rock," the lead surgeon said.

If we repaired her eye, she could die on the table of cardiac arrest or wake up post-operatively with another pneumonia or heart failure.

If we didn't repair it, she could get an infection and could die if it spread to the brain.

Since the family had considered hospice, we too wondered if it was appropriate to put this woman through the stress of surgery at all. Ultimately, after discussions with her family, we did the surgery, and it was successful. The family was satisfied. And the patient survived; her eye is now back together.

The experience got me thinking about the care that we deliver to those near the end of their lives. Researchers have found that a quarter of all Medicare spending - $130 billion this year - takes place during a patient's final year of life.

But who knows? It's hard to forecast what year is going to be the last one. We all have grandparents or parents who decline and then improve, over a drawn-out period. They bounce from lucid to delirious and back.

To many people, it's worth every penny to keep loved ones alive.

This issue arose at a town-hall meeting held by President Obama in February when a woman asked about her 105-year-old mother, who had gotten an expensive pacemaker at age 100. She wondered whether health reform would limit care like that in the future.

The president was blunt. "We as a culture and a society [need to start] to make better decisions for our families," he said. He has talked before about his grandmother getting an expensive hip replacement while dying of cancer, and how it was likely not prudent.

These difficult issues are getting discussed across America. Whose decision is it? How much is too much?

Political opponents of the president have exploited the issue, unfairly in my mind. Former Alaska Gov. Sarah Palin has warned of "death panels" staffed by bureaucrats deciding how to ration care to the elderly, and in some cases, pulling the plug. None of the bills call for anything of the sort.

Health-reform legislation has encouraged end-of-life care as something that people need to consider long before they reach the end of life. In the current House bill, Medicare will create a new code to pay for a non-mandatory, end-of-life care consultation with a physician or other health-care provider.

That's a good idea. But figuring out what a patient wants can be tricky when the patient is demented and surrogates take over. My patient didn't want any advanced life support, yet she arrived with a feeding tube. The surgery had the potential of keeping her on a ventilator for a while. Would she have nixed it just knowing that? That just impresses upon us as a culture the importance of formulating detailed advance directives. In a national nursing-home survey, only 65 percent of patients had advance directives. We can do better.

Medical decisions are nuanced, and it's impossible to predict every permutation when formulating an advance directive. But at least we can try by thinking hard about our last wishes beforehand. And if spelling out our wishes can limit waste and maintain comfort, we all benefit.