Dr Saheb Sahu
Hospitals exist for the acutely ill. And it goes without saying that hospitals should house intensive care units for the care of the critically ill. But what about the old people who are mildly sick or the definitely dying?
The question is, at what point old people should stop going to the hospital? Doctors increasingly turn to frailty assessments to help them determine who will benefit from a particular surgery or drug therapy and who might be harmed by or even die from it. A frail person is one who does not bounce back easily from a minor illness like urinary tract infection or bronchitis or flu.
How to judge frailty? Criteria developed by geriatrician (a doctor who specializes in elder care) Linda Fried and colleagues is most widely used in the United States. It consists of five components. Individuals are classified as “frail” if they are over sixty-five years of age and meet three or more of the following criteria:
- Unintentional weight loss of ten pounds (4.5kg) or more during the last year
- Feelings of exhaustion
- Physical weakness, measured by checking hand grip strength with a dynamo meter
- Slow walking speed, measured as requiring six or seven seconds to walk fifteen feet( 4.5 m )
- Low physical activity.
Studies show that many factors besides old age put a person at risk of frailty. They include: lack of physical activity, smoking, depression, lower educational achievement and mental disability.
Futile Treatments
The first step in determining whether a treatment is futile is to take stock of frailty. A high degree of frailty should prompt some caution with regard to accepting new treatments. The next step is to press the doctor for meaningful answers to the tough question: ‘How much is this treatment is going to help me?’, and “what are the downsides of the treatments?’ You can be even more specific: “What is the likelihood that the treatment will make me so sick that I won’t be able to enjoy things that bring meaning to my life?” What will be the total cost?” How much of it will be covered by my health insurance if you have one? Keep it in mind that doctors in general are adept at offering general statistics. They tend to be more optimistic in general, but you must press them to be more specific about your case.
Palliative and Hospice Care (Comfort Care)
Non-small cell lung cancer (a form of lung cancer) is a bad cancer, and patients with this type of lung cancer survive less than a year. Doctors at Massachusetts General Hospital (USA) wanted to see if they could do something to ease the suffering of their patients. So they randomly assigned those with newly diagnosed non-small –cell lung cancer patients to one of two groups. One group received standard cancer treatment for the lung cancer. The other group received standard cancer treatment plus early palliative care.
The result of the study shocked the medical profession. What really shocked doctors was that patients who received early palliative care lived about two months longer and reported greater quality of life and better moods than those received standard care. Even more impressive, however, is that those who received early palliative care opted for less aggressive medical care as they were dying. This meant that they generally received less chemotherapy and more comfort-focused care in the weeks prior to their deaths. What this Massachusetts General Study showed is that even when the prognosis (outlook for a disease) is grim and the patients are dying, they might live longer when they opt for less aggressive medical care and choose instead to prepare for dying. Other subsequent studies have come to similar conclusions.
Reconsidering Cardiopulmonary Resuscitation-(CPR)-
Most people have misguided belief that CPR is mostly successful. But the reality is much different. In the hospital settings (if your heart stops while you are in the hospital), the success rate for CPR is 24 to 40 %, and it is around 10 to 12 % outside the hospital (USA). However, a report from 115 studies showed a survival to discharge rate (those who survive the initial CPR, but died subsequently before discharge) is 15% in USA, 16% in Canada, 17% In UK and 14% in EU countries. The CPR survival to discharge rates will be much worse in developing countries including India.
Most people also do not quite realize what CPR entails. Effective chest compression can cause fractures of ribs, especially in a frail person. It requires the insertion of breathing tube and mechanical ventilation (respirator). It also requires insertion of catheters in to major blood vessels for the administration of multiple medications to jump start the heart and keep it going. Intravenous catheters become a source of infection. And only around 15% of patients, who receive CPR, survive to go home.
Conclusion
As we become older (65 and over), the prospect of frequent hospitalization looms large. While hospitals play a crucial role in acute and other serious illnesses like heart attack, stroke, cancer and broken bones, there are compelling reasons to avoid them in one’s older years.
Firstly, hospitals can be breeding ground for infections, posing significant risks to seniors with weakened immune system. Additionally, the impersonal nature of hospital environments can lead to feelings of isolation, anxiety, and in some cases depression in elderly individuals. The bustling sterile wards and corridors often lack warmth and familiarity of home, potentially exacerbating existing health conditions. Moreover the financial burden of hospital stays can be overwhelming for most families. For seniors with no health insurance or high deductible health insurance, co-pays and uncovered charges can create undue stress, impacting both financial stability and overall health.
Old age is a continuous series of losses. Our goal at the end-of life should be how to make life worth living when we are weakened and frail and can’t fend for ourselves anymore. Most of us are unprepared for the final phase of our lives. We should take steps, to be prepared. We should ask ourselves:
1- Do we want aggressive treatments such as chemotherapy, radiation, CPR and respirator?
2- Do we want to be resuscitated if our heart stops?
3– Do we want tube feeding or intravenous feeding if we can’t eat on our own?
4– Do we want to die at home or in an intensive care unit of a hospital?
These are kind of questions we must discuss with our family, friends and doctors. We must make our wishes known to them, preferably in writing.
At the end-stage of life most people like to be free of pain or experience minimal pain and be with family and friends. They want to share memories, settle relationship, establish their legacies and make peace with their Maker (if they believe in one). They will like to die at home and not in a hospital. Death is an event we cannot avoid. Let us be prepared and not surprised by it. I will conclude this essay with a quote from Shakespeare:
“Of all wonders that I have heard;
It seems to me most strange that man should fear;
Seeking that death, a necessary end
Will come when it will come.”
- William Shakespeare. Julius Caesar
Ps- Dr Sahu is a retired pediatrician, settled in USA. He has been writing about end of life care issues for mora than 20years.
Sources
1-L. S. Dugdale, MD.The Last ART OF Dying. Harper One, New York: 2020
2-Atul Gawande. Being Mortal, Medicine and What Matters in the End. Metropolitans Books, New York: 2014
