Our favorite Emanuel brother hopes he dies at 75

[SouthernSurgeon]

It kind of reminds me of a lecture I went to once, where a quality of life discussion came up at the end. Someone brought up a study in which people were asked if they would want to continue to live with certain disabilities after an operation, and then people who actually developed those disabilities after the operation were re-polled down the line. Unsurprisingly, a decent percentage of opinions were changed (I'll post the paper here if I can find it).

The study I'm familiar with in this regard is ostomies.

There are a number of people (general surgeons encounter them often) who will state preoperatively that they are 100% certain they would prefer death over an ostomy.

They've done a lot of QOL studies on ostomy patients and found that postoperatively if you study them about 6-8 months out most patients' QOL is either back to baseline or improved.

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[BurghStudent]

Not everyone has insurance, and even if they did that is still not a reason to do wasteful procedures just because a patient demands it.

We put constraints on certain procedures e.g transplants, so why can we not put them on other procedures. Blood for an EtOHer GI bleeder who refuses to give up drinking, IV lasix for the guy who refuses to take his CHF meds etc. Since there is no sense of sacrifice when giving them those treatments, and they have no idea how much it costs, everyone feels entitled to it

Like I said, we do not give treatments based on what patients want, but when it comes to life-saving, heroic measures then everyone's balls shrink up for fear of lawsuits and they acquiesce to every demand, even from the 2nd cousin twice removed who hasn't seen the patient in 10 years

You make an interesting point. If physicians and patients are partners in maintaining health, why is it the physician who faces retribution for mistakes, over diagnosis, under diagnosis etc? Do patients not also bear the responsibility of their health? So, what corrective measures are placed on patients when they are non-compliant? When they continue to worsen their own health knowingly?

 

[DermViser]

You make an interesting point. If physicians and patients are partners in maintaining health, why is it the physician who faces retribution for mistakes, over diagnosis, under diagnosis etc? Do patients not also bear the responsibility of their health? So, what corrective measures are placed on patients when they are non-compliant? When they continue to worsen their own health knowingly?

Well under a P4P type system, patients would be dropped by physicians. I'm ok with that, if it comes to that.

 

[Kaustikos]

Yeah, it's not like it's possible not to have those problems when you're 70+ years old. It's not like there is a chance for medicine to improve in the near future. When you're 70 we'll see how you'll feel.

I just don't like old people lol

 

[Kaustikos]

You're right. You don't.

Meh. Given how I live, I find it depressing wanting to live when you can't live. In a sense: if I can't drive the cars I have then I think I'm done.

 

[Kaustikos]

When it's a close family member and it's a death sentence for them, let me know how you feel then.

Right,
But I could easily make the counter argument of how sadistic and selfish it is to prolong care in someone that may not want it. You think older people auto disagree with what's being said? It's just sad that if an elderly wants to die we auto assume it's ams or depression or suicidal ideations when it could just be that they really don't want to suffer. Or that they've lived their life and don't see the point in prolonging it just because the 15 tablet combo allows it.

 

[DermViser]

Right,
But I could easily make the counter argument of how sadistic and selfish it is to prolong care in someone that may not want it. You think older people auto disagree with what's being said? It's just sad that if an elderly wants to die we auto assume it's ams or depression or suicidal ideations when it could just be that they really don't want to suffer. Or that they've lived their life and don't see the point in prolonging it just because the 15 tablet combo allows it.

I'm actually ok with that, honestly. I used to feel so differently long before med school of how sick it would be for a patient to want to hasten their death. Then you see it with your eyes, and see how selfish you were for even thinking that. I also believe if a patient wants an intervention, procedure, etc. that you believe they should have, then they should get it and third party payers should pay for it.

 

[SouthernSurgeon]

Right,
But I could easily make the counter argument of how sadistic and selfish it is to prolong care in someone that may not want it. You think older people auto disagree with what's being said? It's just sad that if an elderly wants to die we auto assume it's ams or depression or suicidal ideations when it could just be that they really don't want to suffer. Or that they've lived their life and don't see the point in prolonging it just because the 15 tablet combo allows it.

One of the lowest moral/ethical moments of my life came when dealing with one of these situations.

We got a consult for a g-tube on a patient who had just had a stroke. For reasons not pertinent they weren't a PEG candidate so it was going to have to be a surgical feeding tube.

She was 88 I think, total aphasia. The neuro resident had told me it was both an expressive and receptive aphasia. Family wanted everything done.

I was consenting the family for the procedure, and as I was explaining it, the patient just started vigorously shaking her head no, over and over. I watched very closely and was certain this was deliberate. Her daughter actually ultimately went over and started holding her head still.

I stopped the consent and stepped out of the room because I was so shaken by this.

I called my attending and the neurology resident to express my concerns. This resulted in an impromptu family meeting and after neuro's repeated insistence that she couldn't understand what was going on due to her stroke the consensus was made to proceed with the feeding tube.

I felt sick.

Patient ended up being made comfort care and dying I think four days later after she continued expressing herself through shaking her head and someone finally waking up and realizing she was actually being purposeful.

I wish I could say I'd made a stronger moral stand and found a way to stop her prolonged suffering at the hands of medicine sooner. But I didn't. I expressed my initial concern but I should have stood stronger. I'll always regret that.

Medicine sucks sometimes.

 

[DermViser]

One of the lowest moral/ethical moments of my life came when dealing with one of these situations.

We got a consult for a g-tube on a patient who had just had a stroke. For reasons not pertinent they weren't a PEG candidate so it was going to have to be a surgical feeding tube.

She was 88 I think, total aphasia. The neuro resident had told me it was both an expressive and receptive aphasia. Family wanted everything done.

I was consenting the family for the procedure, and as I was explaining it, the patient just started vigorously shaking her head no, over and over. I watched very closely and was certain this was deliberate. Her daughter actually ultimately went over and started holding her head still.

I stopped the consent and stepped out of the room because I was so shaken by this.

I called my attending and the neurology resident to express my concerns. This resulted in an impromptu family meeting and after neuro's repeated insistence that she couldn't understand what was going on due to her stroke the consensus was made to proceed with the feeding tube.

I felt sick.

Patient ended up being made comfort care and dying I think four days later after she continued expressing herself through shaking her head and someone finally waking up and realizing she was actually being purposeful.

I wish I could say I'd made a stronger moral stand and found a way to stop her prolonged suffering at the hands of medicine sooner. But I didn't. I expressed my initial concern but I should have stood stronger. I'll always regret that.

Medicine sucks sometimes.

WOW.

 

[PL198]

I don't see why more taxes are the answer. Why not just make the system more efficient.

 

[PL198]

One of the lowest moral/ethical moments of my life came when dealing with one of these situations.

We got a consult for a g-tube on a patient who had just had a stroke. For reasons not pertinent they weren't a PEG candidate so it was going to have to be a surgical feeding tube.

She was 88 I think, total aphasia. The neuro resident had told me it was both an expressive and receptive aphasia. Family wanted everything done.

I was consenting the family for the procedure, and as I was explaining it, the patient just started vigorously shaking her head no, over and over. I watched very closely and was certain this was deliberate. Her daughter actually ultimately went over and started holding her head still.

I stopped the consent and stepped out of the room because I was so shaken by this.

I called my attending and the neurology resident to express my concerns. This resulted in an impromptu family meeting and after neuro's repeated insistence that she couldn't understand what was going on due to her stroke the consensus was made to proceed with the feeding tube.

I felt sick.

Patient ended up being made comfort care and dying I think four days later after she continued expressing herself through shaking her head and someone finally waking up and realizing she was actually being purposeful.

I wish I could say I'd made a stronger moral stand and found a way to stop her prolonged suffering at the hands of medicine sooner. But I didn't. I expressed my initial concern but I should have stood stronger. I'll always regret that.

Medicine sucks sometimes.

Yeah that sucks but I'm sure being a resident vs an attending in that situation is pretty different with regards to how far you can go

 

[SouthernSurgeon]

Yeah that sucks but I'm sure being a resident vs an attending in that situation is pretty different with regards to how far you can go

Which is why residents are susceptible to burnout and emotional exhaustion, because they often feel caught in a moral quandary and powerless to intervene.

I should have done more. Resident or no.

But I've tried to learn from that. I've since successfully convinced several attendings that a pre-mortem is not a requirement for a dying patient.

 

[DermViser]

Yeah that sucks but I'm sure being a resident vs an attending in that situation is pretty different with regards to how far you can go

Except emotionally it's hard to do, bc YOU are the one getting consent, and YOU are the one doing the procedure. It gets pawned off to you, bc the attending is too chicken **** to put his foot down, so you're stuck. Now imagine having many patients like that with family wanting you to do everything bc they can't let go. It's exhausting.

 

[Mad Jack]

I'd love to finish the article, but my web browser keeps killing itself every few minutes when I open it. Even my OS can't stand EE.

On the one hand, I too don't want to live much past 75. My family has a long standing history of living life well and then cashing in our cards while we still have some quality of life. But I have those views for personal, not economic, reasons. What EE proposes is that life has an inherent declining utility with age and that once that utility has decayed beyond a certain level the person should be allowed to pass for a mix of social, economic, and other BS reasons. Who is he to make the call that life is no longer valuable after 75, that people can no longer meaningfully contribute, and that all lives aren't worth living? Leave that to the individuals you damn crackpot. There's a myriad of personal, spiritual, and religious reasons people might want to be alive after 75.

Also got some serious lulz out of his memorial service while alive nonsense. "They can have their own memorial service after I die, that isn't for me." Or something to that effect. How self-absorbed do you have to be to think that a memorial service is about you to begin with? It's about the people who loved you, the joy you gave them, and the void you have left. It's about them more than it is about you. How freaking self absorbed can you be?

 

[DermViser]

I'd love to finish the article, but my web browser keeps killing itself every few minutes when I open it. Even my OS can't stand EE.

On the one hand, I too don't want to live much past 75. My family has a long standing history of living life well and then cashing in our cards while we still have some quality of life. But I have those views for personal, not economic, reasons. What EE proposes is that life has an inherent declining utility with age and that once that utility has decayed beyond a certain level the person should be allowed to pass for a mix of social, economic, and other BS reasons. Who is he to make the call that life is no longer valuable after 75, that people can no longer meaningfully contribute, and that all lives aren't worth living? Leave that to the individuals you damn crackpot. There's a myriad of personal, spiritual, and religious reasons people might want to be alive after 75.

Also got some serious lulz out of his memorial service while alive nonsense. "They can have their own memorial service after I die, that isn't for me." Or something to that effect. How self-absorbed do you have to be to think that a memorial service is about you to begin with? It's about the people who loved you, the joy you gave them, and the void you have left. It's about them more than it is about you. How freaking self absorbed can you be?

The same type who screams at people for being involved with their Walkmans in parks.

 

[PL198]

lol more support the asperger's conclusion. if someone honestly thinks they should have a memorial service for them-self while they are alive, there's definitely something going on.

 

[Robotman]

Uh oh...

No need for "Uh oh" only for "Yippee"

 

[sinombre]

lol more support the asperger's conclusion. if someone honestly thinks they should have a memorial service for them-self while they are alive, there's definitely something going on.

It's actually a perfect example of something he thinks sounds good in theory, but that wouldn't work in reality (arguably like a lot of his policy).

What does he expect people to do at this pre-death memorial service? "Hey there Zeke. Congratulations on dying soon, I think."

 

[FutureInternist]

You make an interesting point. If physicians and patients are partners in maintaining health, why is it the physician who faces retribution for mistakes, over diagnosis, under diagnosis etc? Do patients not also bear the responsibility of their health? So, what corrective measures are placed on patients when they are non-compliant? When they continue to worsen their own health knowingly?

I definitely agree that patients should be held responsible for not caring for themselves. There was a thread before in which I posted my thoughts on this but, for me, it is about drawing lines after which point you stop all treatment for a patient
EtOHer with a 3rd GI bleed since he wouldn't stop drinking --> no blood for you (soup Nazi voice)
HTN pt w/ 3rd HTN crisis due to not taking meds --> no nitroprusside for you
CHFer who bought iPhone but not $4 lasix --> No O2 for you

The problem is that the value placed on human life is too high in USA, & everybody, regardless of what they have done to themselves, believe they deserve any & all treatment - futile or not.
Since there are NO consequences for pts not doing their part of the bargain, there will never be an incentive for them to change their behaviour & hence costs continue to go up
We already draw lines for certain txs - i.e. No transplants for smokers, drinkers.....I argue with we need new & much stricter lines in order to contain costs and (for me) more importantly, extract some measure of compliance from the patients

 

[FutureInternist]

An antibiotic is not a tx for a viral illness. Has nothing to do with the topic. If the govt. doesn't want to spend money no healthcare then it should get out of the business of it by administering Medicare and Medicaid.

That's the reason I brought it up, since we do SO many things to patients (not for them) that have not shown any benefit, simply because they or the family demand it & as docs we do not have a leg to stand on to say no since then we get sued & our livelihood gets put in jeopardy

If things are mandated by the government then we can be safer in refusing to provide certain procedures etc

As for providing health care, the gov doesn't have an obligation to provide an indefinite amount of money to an indefinite amount of people, otherwise, it would have to give transplants to everyone that needed it (provided it had the supply) & not just to non-smokers, non-EtOHers etc..I am just advocating for stricter lines being drawn

 

[DermViser]

That's the reason I brought it up, since we do SO many things to patients (not for them) that have not shown any benefit, simply because they or the family demand it & as docs we do not have a leg to stand on to say no since then we get sued & our livelihood gets put in jeopardy

If things are mandated by the government then we can be safer in refusing to provide certain procedures etc

As for providing health care, the gov doesn't have an obligation to provide an indefinite amount of money to an indefinite amount of people, otherwise, it would have to give transplants to everyone that needed it (provided it had the supply) & not just to non-smokers, non-EtOHers etc..I am just advocating for stricter lines being drawn

Transplants have clinical criteria for distribution beyond the doctor's control. And no a govt. third payer denying certain procedures doesn't make it safer for the doctor. Malpractice bc they have no case, maybe. But not in interacting with the patient. In all reality, the percentage of patients that actually sue is small.

 

[alpinism]

I'd love to finish the article, but my web browser keeps killing itself every few minutes when I open it. Even my OS can't stand EE.

On the one hand, I too don't want to live much past 75. My family has a long standing history of living life well and then cashing in our cards while we still have some quality of life. But I have those views for personal, not economic, reasons. What EE proposes is that life has an inherent declining utility with age and that once that utility has decayed beyond a certain level the person should be allowed to pass for a mix of social, economic, and other BS reasons. Who is he to make the call that life is no longer valuable after 75, that people can no longer meaningfully contribute, and that all lives aren't worth living? Leave that to the individuals you damn crackpot. There's a myriad of personal, spiritual, and religious reasons people might want to be alive after 75.

Also got some serious lulz out of his memorial service while alive nonsense. "They can have their own memorial service after I die, that isn't for me." Or something to that effect. How self-absorbed do you have to be to think that a memorial service is about you to begin with? It's about the people who loved you, the joy you gave them, and the void you have left. It's about them more than it is about you. How freaking self absorbed can you be?

This is true.

The elderly aren't completely useless.

Old people with Alzheimer's are fun to play hide and seek with.

 

[PL198]

I definitely agree that patients should be held responsible for not caring for themselves. There was a thread before in which I posted my thoughts on this but, for me, it is about drawing lines after which point you stop all treatment for a patient
EtOHer with a 3rd GI bleed since he wouldn't stop drinking --> no blood for you (soup Nazi voice)
HTN pt w/ 3rd HTN crisis due to not taking meds --> no nitroprusside for you
CHFer who bought iPhone but not $4 lasix --> No O2 for you

The problem is that the value placed on human life is too high in USA, & everybody, regardless of what they have done to themselves, believe they deserve any & all treatment - futile or not.
Since there are NO consequences for pts not doing their part of the bargain, there will never be an incentive for them to change their behaviour & hence costs continue to go up
We already draw lines for certain txs - i.e. No transplants for smokers, drinkers.....I argue with we need new & much stricter lines in order to contain costs and (for me) more importantly, extract some measure of compliance from the patients

ex-fricken-actly all we do is continue to incentivize patients who have poor health maintenance and SURPRISE SURPRISE WHAT HAPPENS, the average health maintenance continues to get worse and worse. it's funny because psych is always wanting to expand the classification of mental disease, yet people choosing to buy an iphone instead of drugs to keep their heart pumping, yeah that's totally rational.

 

[DermViser]

This is true.

The elderly aren't completely useless.

Old people with Alzheimer's are fun to play hide and seek with.

I realize you're trying to be funny, but your lame attempt at joke fell flat.

 

[FutureInternist]

Transplants have clinical criteria for distribution beyond the doctor's control. And no a govt. third payer denying certain procedures doesn't make it safer for the doctor. Malpractice bc they have no case, maybe. But not in interacting with the patient. In all reality, the percentage of patients that actually sue is small.

I did fellowship in a kidney TxP center...trust me there are plenty of things that the doctor can hem & haw over, effectively denying that pt a TxP
The criteria are vague enough that calls have to be made regularly
If a 40 y/o pt w/o any FMHx requests a Cscope, I can tell them the guidelines & hence have "back-up" but when we try to dissuade the family from doing something for/to a 85 y/o then things get murky since there are no guidelines

 

[FutureInternist]

I realize you're trying to be funny, but your lame attempt at joke fell flat.

Kind of like old people..ba-dum-tiss

 

[DermViser]

Kind of like old people..ba-dum-tiss

 

[PL198]

Kind of like old people..ba-dum-tiss

it took me a fair bit of time to figure out the ba-dum-tiss

 

[Rirruto]

This is true.

The elderly aren't completely useless.

Old people with Alzheimer's are fun to play hide and seek with.

"Hmm, I guess they're right. Senior citizens, although slow and dangerous behind the wheel, can still serve a purpose." - Lloyd Christmas