Friday, April 03, 2009

L'Chaim...

So I'm in the middle of a two-week stint of Geriatrics right now. The topics of the day invariably surround the most depressing parts of medical practice. We have the incurable chronic conditions, the terminally ill, the demented, the depressed, the disabled and the debilitated. How many times have I heard the term "health care proxy" this week? I can't even guess. Palliative care; "sedation therapy."

Which is more depressing - nursing homes or hospices? At nursing homes the residents are generally demented and seem to exist in a sad world of juice boxes, patronizing nursing staff and the pervasive smell of urine. A second childhood? Perhaps. More akin to a gentle warehouse where they wait for...y'know. At the hospice the patients are generally making the good faith effort to gradually complete their wretched existence which at the end revolves around their particular personal horror. Yet their families want them to die "with dignity." Ha. Dying with dignity is among the most mythic of all ideas. There is no dignity in death, folks. None at all.

Are these the successes or the failures of modern medicine? Thanks to modern medicine we've destroyed the previous strongholds of the Angel of Death. Infectious disease, once the major killer of humanity, has now largely fallen thanks to germ theory and antibiotics. Women dying in childbirth is today only a remnant of the merciless killer of a bygone era. What we are left with are the chronic conditions like heart disease, COPD, and cancer. We are so good at keeping people alive longer that more of them successfully make it to a state of debilitation and dementia. On the one hand, of course it is better that people live longer (and presumably better) lives today - but on the other hand, they weren't storehousing people in nursing homes and hospices in the past. Of course we are glad when a person survives an ordeal that would have easily taken them in a previous century, but we then all too likely send them on their way to a possibly worse ordeal before they take their final leave. Better? Depressing. The Angel of Death is less brazen today, but he makes up for it by being more sinister.

There is no mystery for why this is so. Evolution via natural selection is a great problem solver but it applies its solutions jealously only towards the primary goals of survival and procreation. The human body is incredibly complex and works amazingly well - but only for the first few decades of life. Y'know, the decades where the procreation and raising of young takes place. After the children are grown the elder generation no longer serves a much adaptive role. They are expendable. Natural selection stops working its problem solving magic on the likes of grandparents and soon enough the human body breaks apart on predictable fault lines. If the human body is like an automobile - modern medicine has largely cured the likes of a head-on collision, but after driving hundreds of thousands of miles even the best designed car will be totaled by an accumulation of wear and tear.

Ideally the purpose of medicine is to cure disease - not to let disease win. Yet palliative care is about letting the disease takes its natural course while treating the symptoms. Perhaps we need to recognize our limits since medicine today is still remarkably primitive in many ways, but palliation is still the real booby prize of medicine. The patients suffer less but they still die. There are no victories, only slightly less bitter defeats.

10 comments:

Miri said...

True enough, but one has to take into consideration the following things:
1) Man is mortal. Is it really the object of modern medicine to make man immortal? And if it were, by what standard are we to determine that immortality is the ethically and morally sanctionable goal?
2)I have never been an old person; but it seems to me that the extra years spent on this earth in the company of loved ones may for many be worth the suffering and indignity those years include. Although I imagine that differs from individual to individual.
3) I don't know about you but I'm terrified of death and would prefer to defer it as long as possible. Granted this perspective may change when I get older, especially considering the living conditions. but for every suffering, sick and/or elderly person who says "I just want to die already" there's at least one to match him saying "I'm not ready to go yet."
My point is that while it's depressing and sometimes seemingly futile, I think both hospice and nursing homes still fill a very viable need.

DrJ said...

Perhaps if you could be exposed to another side of geriatrics--geriatric rehabilitation-- you could derive some satisfaction in actually being able to help these patients and their families to cope with their new situation. This is much less depressing. These patients do improve and are greatful for the work that you have done for them.

PS I am a rehabilitation physician.

Anonymous said...

After having two elderly parents go through several years of illness, disability and suffering. the kindest words I ever heard were from a wizened old male nurse. During my mother's last hospitalization, he held hands with my siblings and me and said "I consider all of you my patients. I am here to care for all of you," and he did. The lesson for Orthoprax as a young dr. in training is that even if you can't heal the true patient, how you care for them and how you treat the family members can help heal the familiy.

Conversely, you also have the power to cause a lot of harm. Several years later, I have nightmares about the hospitalist who was assigned to a loved one while she was dying. She was completely oblivious to her suffering, couldn't understand that the normal dose of morphine wouldn't work for a dying person who already had been on huge doses of opiates for years, and was rude and nasty to the family members watching a loved one die.

You aren't as impotent as you might think. You do have the power and skills to ease suffering or to cause harm.

Jeff said...

OP,

Each branch of medicine has its own culture and language. Each one thinks the other at least some extent stupid and crazy. Right now, I think your are using a med/surg viewpoint: Fix one problem then the next.

I do no think the purpose of medicine is to cure disease, but improve the quality of life, which often includes curing disease. Many times adding life to years is far more important than years to life. Public health docs call it I think "quality adjusted years of life" when figuring out cost/benefit.

Hospice may not be perfect, but it sure beats high level nursing homes (i.e Select Corp.) where I have personally coded the same patient 3 times in on night.

But again, what is the Jewish perspective? My understanding is that first ones obligation is to prolong life as long as possible, Perhaps because the body and soul together are a special holy entity, albeit less refined than the pure soul. Perhaps because that persons job isn't done, or they might be moshiach.

On the other hand, there can be great physical pain in dying, and spiritual pain in the soul's separation from the body. Ideally it is the triumphant return of the spirit to god with its task done. I call that dignified.

No dignity in death? So bitter so soon OP, wait till intern year ;)

Jewish Atheist said...

I heard once from someone who worked at a nursing home that the majority of people do not end up in one. Do you know if that's true?

Also, as others have alluded to, the doctor plays many roles other than simply "fixer." And I have personally witnessed a death that I would could dignified. Surrounded by loved ones, at peace with what was happening, wishes made clear. Then they turned off the machines and she was gone in a few minutes.

Orthoprax said...

JA,

"I heard once from someone who worked at a nursing home that the majority of people do not end up in one. Do you know if that's true?"

Majority? That's probably true. Old statistics have it that if you make it to 65 then you have a 43% chance of entering a nursing home. That statistic also consists of 52% of women who make it to age 65. Something like 25-30% of Americans die in a nursing home.

That said, there's been plenty of changes in the last couple of decades with different versions of home care and assisted living institutions bridging the middle ground between being on their own and living in a nursing home. Odds are that the chances of entering a nursing home will decline as these other options become increasingly popular.

"Also, as others have alluded to, the doctor plays many roles other than simply "fixer.""

Yeah, I get that. It's just not really my bag of tea. Jeff implied that I thought palliative care and the like is stupid - it's not stupid, it's just not a part of medicine which I find remotely satisfying.

I'm a technical kind of guy - I like the diagnosing, selecting the right treatment and then being able to see the patient get better. Having a futile treatment plan with death being a "success" - well, let's just say I'm glad there are other people who are willing to do it.

"And I have personally witnessed a death that I would could dignified. Surrounded by loved ones, at peace with what was happening, wishes made clear. Then they turned off the machines and she was gone in a few minutes."

I believe one can approach death with dignity, but death itself is pitiful.



Jeff,

"I do no think the purpose of medicine is to cure disease, but improve the quality of life, which often includes curing disease."

Heh, in part. But if the goal was to improve quality of life then there are plenty ways to do that outside of healthcare. In fact, I'd argue that stam quality of life is best supported by the likes of technology, entertainment, etc.


Miri,

"Man is mortal. Is it really the object of modern medicine to make man immortal? And if it were, by what standard are we to determine that immortality is the ethically and morally sanctionable goal?"

Death and disease are the enemies of medicine. I don't know if the goal is a true conquest of death, but we do want to dull as many of its barbs as we are able.

"it seems to me that the extra years spent on this earth in the company of loved ones may for many be worth the suffering and indignity those years include. Although I imagine that differs from individual to individual."

Probably. Except many elderly people live alone - and die alone. To be short, I wouldn't spite anyone longevity but it comes at such a price! I don't dread old age, I dread infirmity and dementia.

"My point is that while it's depressing and sometimes seemingly futile, I think both hospice and nursing homes still fill a very viable need."

Of course, but it's an ironic need. Behold ye the successes of modern medicine.


DRJ,

"Perhaps if you could be exposed to another side of geriatrics--geriatric rehabilitation-- you could derive some satisfaction in actually being able to help these patients and their families to cope with their new situation."

Could be. But to be honest the whole idea of helping people cope doesn't suffice when an alternative career path is in the curative fields. I like big successful outcomes.


Anon,

"The lesson for Orthoprax as a young dr. in training is that even if you can't heal the true patient, how you care for them and how you treat the family members can help heal the familiy."

Seems to me like a doctor isn't what is called for when what is really needed is just a warm hand and a supportive disposition. Sure, that's part of being a doctor, but having that disposition isn't the special skills that distinguish a doctor as a doctor.

Jewish Atheist said...

Yeah, I get that. It's just not really my bag of tea

Hey, at least you recognize that! Good for you. Stick with what you like. You'll do best there.

Jeff said...

OP,

?Your thoughts on halacha (and my above comments) for a painfully dying man who wants hospice?

And of course technology improves health and quality of life most, but docs mostly don't do that. I'm just saying that changing the perspective (to quality vs cure)changes the interpretation.

Orthoprax said...

Jeff,

I think the basic halachic view is that life is to be prolonged as far as is possible but futile gestures that may cause suffering is to be minimized.

Anonymous said...

So how does it feel to study something that one day will envelope YOU if your'e lucky!