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This month EPM focuses on geriatrics. Geriatrics should not be taken as merely a small subdivision of emergency care within the larger health care question. No, it is the fundamental issue of our time. How we handle the elderly essentially defines who we are. Leadership in this arena has been seriously lacking since the end of the Second World War. No president, democrat or republican, has had the courage to carry on the national conversation which is necessary to decide what we are going to do as we age.

Science will never answer this question. Science is neither moral or immoral. It is amoral. It is always good to remember that the scientists who built the gas chambers at Dachau were perfectly good at science. They were just perfectly bad at philosophy. Similarly, what we do in medicine is a science question. Who we treat and when we treat are philosophical questions. And philosophy must lead the science where the society wants it to go. What leads us is more important than who leads us on this issue.

The geriatric healthcare issues which are set before us constitute – depending on what you include in the pile – 75% of the US expenditure in medically-related issues. The elderly consume about 85%, on a cost basis, of all the medications produced in the United States. The use of X-rays and CT scanning goes up logarithmically with age. And, no one likes to carry on the conversation that as we continue to spend, the return is less and less. Just the geriatric portion of health expenditure is now the largest single industry in the world. It is the principle expenditure of the federal/state government, larger than defense and just ahead of the looming giant of the interest on the national debt.

I believe that the issue in front of us is to separate out two entirely different practice questions. The first one is the science of medicine; the second is the science of care. I never believe that I have nothing to offer a patient. I always have something to offer every patient. But we should understand that at a certain point in time what I have to offer is comfort and care and not necessarily intensive application of diagnostic and therapeutic science. These two approaches have almost nothing to do with each other.

On my last shift I saw an 87-year-old gentleman sent from the nursing home. He lives at the home because he is demented. Essentially the family, including his wife, are waiting for him to die. Why was he sent to the emergency department in a somewhat dehydrated condition? Is it because we’re afraid to let people die in nursing homes? Is it that we feel so guilty about the way he’s been handled throughout his life that now, at the moment of death, we must go through ridiculous rituals which have nothing to do with extending any meaningful life? This primitive tribal ritual of beating on chests and inserting tubes and wires can only be considered barbaric in the extreme.

If you’re wondering how I handled this demented patient, I’m happy to tell you. I gave him three liters of fluid, he perked up a little bit, he appeared to his wife to look as he usually did, and sent him back to the nursing home. There was no way that I was going to put this gentleman – who had lived a full and productive life – through ridiculous hoops in the end. He could not identify his wife when he left, but he couldn’t identify her the day before, or the day before that. He was no worse off than he had been. To have repeated a CT scan of his head – which had been done only a few weeks before – and to do a huge metabolic work-up in someone who is demented and somnolent on the best of days, is to belittle his dignity and to deny reasonable assistance to his grandchildren and great-grandchildren who are in true need of services.

If President Obama truly wants to lead, if he desires a “health care fix,” then this is where he needs to go. The national conversation needs to decide what health care we are going to give out and to whom. Until we realize that we can’t do everything for everyone and there needs to be some rational rationing of care, I’m afraid we are destined to crucify our children on the altar of the expanding national debt.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.

 

Comments   

# bonofides=blue collar ER docDr Sourbutt 2009-06-09 19:38
Congratulations on not caving in this time Greg...how 'bout when he bounces back tomorrow night with all the great and grand kids?...there has to be a disincentive (of course financial) for these nursing homes/doctors to "OK" the transfer in the first place. Also you didn't mention whether you were able to precertfy him for a "free Medicare" Hoveround Power chair.
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# Medical DirectorDr. Mirarchi 2009-06-10 12:14
Greg,

Elderly demented and debilitated patients will always present and we will always be faced as to what to do. Do we do everything, something or nothing? Who decides? Also what do we do with patients with worsening illnesses that are not end stage yet but we know they will be? Do we stop treating them too? Do we stop treating easily treatable and reversible medical conditions like an exaccerbation of CHF? Where do we get protection from all of this?

Truth be known if the family or decision maker of this patient you spoke of pushed the issue, you would be forced to treat them or be faced with administratativ e or legal hassels.

I would be nice if we could make decision that we felt were right for the patient but I do not see that happening anytime soon.
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# Where's the PCP/nursing home doc in all this?Jim Mensching, DO 2009-06-12 05:38
I'm glad you had a reasonable and prepared family to deal with. That's about 2 out of every 10 similar scenarios. The other 8 are those family members with whom no one has had an honest discussion of what lies ahead for their loved ones. Those 8 patients get tortured with futile workups because (a) the family isn't ready to let go and (b) we don't want to deal with the inevitable complaints/thre ats of lawsuits because we wanted to let Nana die.

As a start, we should demand of our colleagues in primary care that they have "the talk" with the patient and all relevant parties and be up front about what's realistic. It's one more burden they've put on our shoulders to deal with at 2 in the morning.
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# jb 2009-06-13 16:35
I agree 100%. The problem is not one politician has the guts to say this. Here in North Dakota our own Kent Conrad talks about how we won't ration care with this new plan. We have to ration care. We are going broke because patients and their families want it all done to "just give it a try." After all, it's "free" why not?
In contrast,just north of us in Canada an editorial in The Winnipeg Free Press written an ethicist for the University of Manitoba talks about the elderly's duty to die at some point as to not burden the system. What a differnce of thinking despite less than 200 miles of distance.
I am a libertarian, but as long as people want something paid for by the government, they have to accept reasonable limitations, and we need to be provided with legal protection in promoting those limitations.
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# Geriatric CareJerald Reisman, M.D. 2009-06-18 16:40
Dr. Henry,
When is this country going to come to terms with the fact that we don't have unlimited funds to give care that should not be given. I had a 99yo demented nursing home patient (that I have cared for numerous times) sent in by her nephrologist because her dialysis shunt wasn't working. Each time I care for this patient, I tell the nephrologist he should be in jail for doing dialysis on this patient. Would the family choose dialysis for this woman if they had to pay for it? I don't think so. They would have let her die with dignity years ago. When will we come to terms with this behavior?
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# Jeffrey Caterino, MD 2009-06-19 17:44
The danger and challenge is - who will decide? The ED doc at 2AM? The family doctor who has known the patient for months or years? The famly? The government? I would think that the ED doc would be in the worst position of these ( with the exception of the government) to make such a decision. The sad thing is that most families are reasonable - if someone trusted takes the time to explain, comfort, etc. This is a large change from 10-15 years ago when most families had not even considered these issues. Unfortunately, too often no one has taken that time. The role of the ED MD would best be to begin this conversation, within the limitations of one single, high-stress visit. I don't think any of us in the ED have the time to do it properly. But planting the seed both with the family and family MDs may be a good start.
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# Medical DirectorFred 2009-06-26 21:11
Greg may get his wish. They are looking to use living wills as a part of health care reform

http://abcnews.go.com/Health/HealthCare/story?id=7817908&page=1
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# geriatric philosophyTom Arnold, MD 2009-07-09 05:54
The essential point here is to examine the individual, and to be frank about the condition and prognosis. Generally these are low odds propositions, but not always. Examination of the patient includes an analysis of everything about them, the gestalt, emotions included. An unbiased and dispationate but caring evaluation is needed for all patients. One must have a clean slate...we are to serve another's best interest. It's the grandmother theory...treat all persons with a good natured equanimity. An excellent article. Tort reform will help but a change in attitude of physician and family is what is most needed. We are physicians, not technicians. Knowing is difficult...but rewarding.
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