AMSA's 2015 Annual Convention
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February 26 - March 1, 2015 

Life’s Quantity/Quality Question

Future physicians should be ready with an answer

The New Physician April 2010

treeIf you’re lucky, growing old is inevitable. If one of life’s many misadventures has not stolen this wonderful and exciting experience from you and you are still alive, you might find it useful to step back and assess the situation. You might discover it’s time to take more control of certain things in your remaining years than you heretofore have been accustomed to.

As I enter this period of my life, I have come to realize that there are several “facts of life” that I need to rethink, facts of life that made some sense when applied to a younger me. Facts of life that may not be as applicable to me as an “old man.” I turned 78 last November, for those of you who may be wondering.

All my life, I was vaguely aware that I would die at the end, but that end was a long way off. To be honest, like most young men, I probably believed I was somewhat invincible, and often took risks that in later years were unthinkable, risks with my physical adventures as well as risks with my health. The end of my life was too far in the future to think about. Meanwhile there was much more to concern myself with before I got to the end: high school and college to finish; a livelihood to establish; a spouse to find and win; children to raise; much stuff to buy; and grandchildren to admire and enjoy.

Now that these endeavors have all been accomplished and are rapidly receding into the past, that end I always thought was so far in the future is coming into view. That end I so rarely thought about in the past is now something I think about often.

I wonder what the last few years will be like. Will I suffer through a long period of being alive, but not really being alive—alive by definition only? Visit any nursing home and you will see many people in that condition. I can’t help but wonder if the added years are welcome. They often end with longer stays in nursing homes, final days in advanced stages of declining health often accompanied by much physical discomfort, and major medical bills left to your spouse or estate.

Those who keep records of such things tell us that a quarter of all Medicare money is paying for services needed in those final years of life. It would be interesting to poll nursing home residents to get their opinion on whether those added years are a blessing or a curse.

A couple of years ago, tests revealed that I needed heart bypass surgery. I reluctantly consented, a decision that to this day I am not sure was the best one for me. I am sure it added years to my life. At 78, I have outlived my father by 10 years. I have outlived my grandfather by 20 years. However, old age takes its toll on my body, I find myself becoming more and more apprehensive about those final years that the heart surgery gave me, ones that may very well be spent in a nursing home.

As I lay in post-op recovery, I asked my nurse, “If you could choose how you will die, what would you choose?” Nurses in post-op are used to strange conversations with patients struggling out of their anesthetic fog, but I sensed by her expression that this was a new one.

She suspected I was leading her into a trap. She reluctantly said, “Well, I guess it would be to quietly die in my sleep.”

“Then it would probably be by heart failure, right?”

“Yes, probably,” she answered again reluctantly.

“Then why do we go through all this trouble to avoid this type of death?” I asked. She didn’t answer right away, but her expression told me I had made her think.

“Well,” she said, “I guess it’s because we are not ready to die.”

Not ready to die. As I thought about that, I realized she was right. I had agreed to the bypass surgery because I was not ready to die.

But how do we decide when we are ready to die? Before we explore that question, we must realize that this is a decision we can make.

Medical advances have progressed to the point that we now are often kept alive far beyond the point that we may choose. However, rather than leaving that decision solely up to the health care providers, we, as patients, can and should take an active role in that decision. Rather than waiting until we’re at death’s door, after suffering through weeks, months or years with an illness, patients can conduct an ongoing dialogue with their health care providers wherein we discuss the pros and cons of the health regimen being prescribed. What is the doctor attempting to accomplish with this medication? What effect will it have on my current health? Will it make me feel better? What are its side effects? What information will these tests provide, and how will this information be used?

Most patients are uncomfortable with questioning their doctors in this manner. We have adopted an attitude of “whatever the doctor orders” for so long that it’s difficult to step into a new role of assertiveness. However, it takes on added significance when we are attempting to shape the end of our lives.

There may be some irritation on the part of the doctor. The doctor may feel that the patient is questioning her judgment, but if we are persistent and courteous, she hopefully will come to realize and understand that there is mature thought behind the questions. Hopefully the doctor will realize that the patient’s concern is in trying to picture the quality of life this regimen will foster. Will it improve or maintain our present quality, or is it designed to extend life into that stage of alive-but-not-alive that we want to avoid if at all possible?

We patients are more interested in quality than quantity. Hopefully our doctors will switch their priorities from helping us live as long as possible to focusing on providing as many quality years as possible.

Personally I won’t presume to tell her how. I will bow to her knowledge. I won’t tell her what medicines to prescribe, and I won’t say what tests to schedule and what tests to ignore. Once I see that we are on the same page, I’ll let her guide me to my final destination.

As medical science continues its march, advances that often can keep our bodies functioning far beyond enjoyable years, patients need to take a more active role in their health care decisions, and doctors need to help us do so.

John Croft lives in Cambridge, Ohio.