Reply to Bias towards elderly who will not go quietly

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[quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous][quote=Anonymous]Absolutely terrible thread title, BTW. [/quote]

Agreed, it is a disgusting title.

I am an attorney who changed careers and have been working in mostly hospice care for the last near decade. The majority of my patients have been elderly, but some were DNR based on chronic degenerative conditions at younger ages.

I’ve noticed that the majority of doctors are just as uncomfortable as the average person with having conversations about death. They may be more matter of fact about it in their own thinking, but they don’t really want to talk about it with patients. There is a lot of avoidance of spelling things out plainly to people who are avoiding accepting it themselves. Even some doctors and nurses who work in HOSPICE, whose jobs are all about helping dying patients die, sometimes push too far to keep people on the alive side of things even if it means prolonging discomfort.

I can’t agree with your OP at all, not the ugly thread title. The truth is that the situation in American medicine is overwhelmingly the flip side of the coin - we spend astronomically to keep people alive in the final years or months, and often causing much anguish in the process for patients and families alike. All because we can’t talk about death in this country and most folks are terrified of it.

As to your parents OP - this is a well tread area of medical ethics and not some ageism bias of the doctors. When patients are in their 80s and beyond, they are statistically much less likely to fully recover from many procedures and treatments - exponentially less likely than a patient in their 50s, 60s, or even 70s. Same with their statistical likelihood of experiencing complications which hasten greater disability and/or death.

This factors into the physician’s determination of what is in the best interests of the patient, and no doctor is required to perform a surgery or treatment on a patient if they feel it is going against their best interests. Some doctors are skilled at explaining this and others just hem and haw and avoid flat out saying how things are. It has nothing to do with a lack of caring about your loved one. I would argue that there is more caring on offer from someone who nudges you in the direction of recognizing your impending mortality than in steering you toward further denial.
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[b]The patient alone determines what is best for them. [/b]Physicians may be learned intermediaries but they have no right to decide whether a patient gets treatment or not. They have a duty to explain all options and the likely results of each. If they can’t do that, they should switch to pathology.

Not everyone who resists being “nudged” toward the beyond is in denial. Some just have more hope than the people doing the nudging. [/quote]

No, patients don’t dictate their care. You can’t just order a doctor to do this or that, if it’s not medically indicated. No wonder so many people are leaving the medical field. You think you can boss them around like they’re your nanny.[/quote]

While medical arrogance may know no boundaries, it is the physician’s duty to explain options and associated prognoses. Failure to do so is prima facie negligence. What is “medically indicated” is a matter of opinion, and patients have a right to have that opinion and the grounds for it made clear. Hiring a physician to provide services does not create a custodial relationship where the physician holds the power of life and death to be exercised at his or her caprice. Oh, and I don’t “think” I can boss the Great Exalted around, I know I can, and I do. [/quote]

You can certainly shop around to find someone to do what you want, if you can find someone to do it. You can't force a doctor to do what you want, if they do not believe it is indicated. You just can't. That's the nature of a profession with a professional license.

Sure, maybe they humor you if you want to "boss the Great Exalted around," if what you want remains within the standard of care, but that's not the same. They are in charge of them. You are in charge of you. If you are able to make decisions for yourself, then nobody can force you to do anything. But you also can't force them -- both sides have autonomy.

Don't forget about this:
1. 2011, How Doctors Die: https://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/
2. 2015, How doctors want to die is different than most people: https://www.cnn.com/2015/08/10/health/how-doctors-want-to-die/index.html

"It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently."

I'm the doctor above who talked about breaking ribs giving CPR. I still hate that feeling under my hands. You don't forget it.

All the docs I know have plans about this. The ones I've discussed it with have identified someone close, usually a colleague, to make absolutely sure extraordinary measures aren't taken in the wrong circumstances. I'm currently in my 50s and have a chronic congenital cardiac condition. I think about this a lot, actually.

Am I okay with someone making a different decision? Absolutely. I defend your autonomy, too, even when you are not able to for yourself. I try to make sure I know your wishes and follow them if I can. I did this for my mother as she was dying, too, as I had medical power of attorney and knew she wanted every chance.

But no, you can't bully me when it's not good care. That's not because I'm exalted; it's because I have a license to protect. I didn't accept money under the table to circumcise a grandfather (WTF, and you are also now banned from my clinic), and I don't get bullied into prescribing addictive drugs just because you want them, and I don't participate in pill farms or anything but the same daily slog through doing the hard work and engaging in shared decision-making with people trying to do their best as we work together on it.

However, I'm likely not going to die like you do. Neither are most of my colleagues. That might not change your mind, and I respect that. But you should know it.[/quote]

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