End of Life

The CNN lede is “Report: U.S. is uncaring place to die“, pointing out that about 1/2 of deaths occur in hospitals, despite “…70 percent of Americans (saying) they would like to die at home”. This is a press release from an organization called “Last Acts“, ‘A National coalition to improve care and caring near the end of life’.

Disclaimer: I personally know nothing about this organization, and do not endorse them specifically; I lack the time or interest to investigate them. If they wind up supporting communism, or moon colonies, or anything else not expressly described in their title and subtitle, I’m not for it. Also, the “1/2 of all deaths occur in hospital” number seems a little suspect to me; a tremendous number of people wake up dead and are transported to the ED to be Pronounced Dead, therefore ‘dying on arrival’ at the hospital. There is an entire exposition in that, and that’s not my point today.

However, what this brings up is an point that comes up a lot more often in my practice of emergency medicine than I’d like: What does Grandma want? I ask this question often, when family members accompany very ill people to my ED, and I ask them, usally like this: “I don’t think this is going to happen in the next 30 minutes, but, if your Grandma’s heart were to stop, or she stops breathing, what does she want?” One time out of 10, they tell me exactly what Granny wanted, and I have the answer; whether I agree or not isn’t the issue (another exposition), but I know what their desires are. (I ask the patients, if they’re well enough, and a surprising number tell me to make them comfortable but to perform no heroics). I do not really care about the “Notarized, Original, Dated Form”; what I want to know is, what did she want, and does everyone know it. The form is only useful when the family disagrees.

What never ceases to amaze me are the number of cases where I am, clearly, the very first to bring this issue up with the family, or the patient. This often occurs on readmission to the hospital after a lengthy, often obvoiusly terminal illness, often from a nursing home or rehabilitation facility, meaning that at least one person (the nursing home admissions person), and hopefully two (above, plus the patients’ physician). I do not discount that people don’t hear what they don’t want to hear, but I feel this isn’t the case.

This is why, recently, we’ve had a lot of dinner-table discussions about end of life matters. Now we have it settled, and I feel better about it. It’s also why we don’t have a lot of dinner guests.

Talk to your loved ones. You never know when it’ll come up.

Update: Medpundit has, as usual, a more eloquent take.