“I don’t have to eat broccoli, I’m President.”

 

A patient reminded me of George Bush Sr.’s statement.  I was admonishing her about eating better.  Her polite reply.  “I don’t have to eat, I’m 100 years old.”

 

She also reminded me of an Eskimo elder hard pressed to keep up with the migration asking for a little food cache to stay behind and rest, all present knowing full well that would be fatal.  As a child, I was brought up thinking that Eskimos left their old people on an ice floe to die because they were hard-hearted, primitive tribes who didn’t know any better.  Life as a nursing home medical director has taught me that it might have been a matter of autonomy, the oldster’s right to give up an unbearable struggle.

 

Those of us who are older can talk to our younger relatives about our feelings and desires about end of life care.  All of us should talk to someone.  As a physician who talks to the responsible relative of recently incompetent patients, I frequently say, ”What do you remember hearing aunt so-in-so say about these feelings and desires?”  A well remembered such conversation is a godsend to all of us present because the responsibility for the decision is at least partially transferred to the patient and the responsible relative is just the messenger to me, the attending physician.  Most of the time in these conversations, it is easy to reach a meeting of the minds because all of us start out on the same page, but there are notable exceptions.

 

An example:  the HPOA (healthcare power of attorney) was a daughter who lived nearby. A son who lived 1000 miles away and seldom visited was convinced that we were ethically obligated to do everything possible to prolong life in spite of severe dementia and a gangrenous foot which several surgeons had declined (refused is a better word) to amputate because the lady was dying of dementia and the amputation would be extra unnecessary pain.  At this point, the mother developed anemia.  Chronic infection produces anemia because the body is sequestering iron, which is more vital to the infecting microorganism on a day-to-day basis than it is to the patient.  So on balance the anemia under primitive (pre-antibiotic) conditions might indirectly favor the host’s recovery.  The son insisted on blood transfusions.  I was reluctant to spend the donated blood supply on a futile gesture and suggested a consultation with the hospital ethics committee and it was a Catholic hospital.  The committee took the case because the patient had previously been a patient at that hospital.  Their conclusion, bless their hearts, was that blood transfusions in this context were intrusive, invasive and inappropriate when only comfort measures were indicated.  The Ethics committee even mentioned that we had an ethical obligation to blood donors because blood donation is similar in principle to organ donations.

 

While a medical student in the 1940’s, I attended some elective discussions about Catholic ethics as it pertains to medicine.  The Catholic diocese in upstate New York sponsored these sessions.  Although I never intended to become a Roman Catholic, the information has been useful to me throughout my career in more ways than just dealing with Catholic patients.

 

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 We have already discussed one example in caring for dying patients.  There is no ethical obligation to prolong life by all available means; only “ordinary means” not “extraordinary means” are required ethically. Of course, other considerations sometimes indicate that more extraordinary means are appropriate.  At that time it was extraordinary to administer water and glucose by needle and it was usually done subcutaneously because it had not been discovered how to remove pyrogens from the water reliably.  Pyrogens are infinitesimal amounts of substances present even in distilled water, which cause fever when given by vein.

 

As new technologies emerged, at first “ordinary means” were advanced on the list to include all but the newest most extraordinary technologies.  Gradually it became obvious to most of us that this was quite arbitrary.  Ordinary now means what can be done by anyone without any technical equipment or expertise, an example of common sense

occasionally prevailing.  

 

In modern America, we are given maximum autonomy in these matters, but in the case of incompetence, it must be autonomy by proxy.  This means talk to those near and dear to you.  Get the instructions for a healthcare power of attorney (see page 82).  You can understand these instructions and accomplish your purpose.  A living will is an alternative to a healthcare power of attorney.  A living will attempts to cover all foreseeable circumstances and this may get complicated.  Without either of these two documents, your relatives may be compelled to go to court for a guardianship if you are unable to act in your own behalf.  Even young people should make these arrangements because of accidents or rare illnesses which cause brain damage.

 

In other parts of the world, physicians are given the authority to determine when further active treatment is futile, perhaps a side effect of publicly funded medical care, but insurance interests could create an even less satisfactory result.  But this is modern America.  The healthcare power of attorney permits you to attain autonomy by proxy without formal legal assistance.  Get the instructions for filling out the health care power of attorney document for your state of residence and act.

 

John A. Frantz, M.D.

Chairman, Board of Health

Monroe City Council

November 18, 2002

 

 

You really can teach an old dog new tricks.

But plan on a dickens of a long campaign.

       

from personal experience