End-of-Life Choice, Palliative Care and Counseling

Posts Taggeddementia

Patient input critical in end-of-life decisions

By Dan Morhaim
SunSentinel.com
June 30, 2012

As an emergency room doctor, I’ve seen this all too often.

An ambulance brings in a frail, elderly nursing home patient with shortness of breath, irregular heartbeat, and plunging blood pressure. The wasted and contracted limbs indicate years of incapacitation, and the medical record reveals a long history of dementia.

As we intensely work to restore stability, probing paper-thin skin for a vein, the patient suddenly goes into cardiac arrest.

Does the patient have an Advance Directive or a Do Not Resuscitate (DNR) order? The answer is no.

And so the ER team goes into full CPR mode, cracking brittle ribs with each chest compression. If “successful,” the patient will endure pain and confusion that may last for the rest of his or her life, however short or long that may be.

Is this care, or is it actually something closer to torture?

The only ethical and legal way to avoid this scenario is when patients have made their wishes known in advance and appointed someone they trust to make decisions when they are no longer able to.

There comes a time when most of us would choose to allow a natural death, rather than use medical technology to prolong life for what is usually only a few extra hours, days, or weeks. But when that moment comes, we are often not in a position to speak for ourselves.

Americans cherish the right to make their own medical decisions. In light of this ardent individualism, it’s puzzling that so few of us exercise this when it comes to something most of us will face: medical care at the end of our lives.

Studies show that only about one third of the general population has completed advance directives, even though these forms are free, straightforward, easily available, and legal in every state. Advance directives empower individuals to manage the final chapter of life in a dignified manner and according to their own values.

These forms, which allow you to specify the kind of care you want as you approach the end of life, offer something rare and important in our modern medical system: an opportunity to exert influence.

As the baby boom generation reaches its senior years, as new lifesaving medical treatments are announced almost weekly, and as our health care system confronts a crisis of affordability, the need is urgent for everyone to demand participation in end-of-life decisions.

While cost is not the primary reason to have an advance directive, saving money is one of its consequences. Medicare estimates 25 percent of its expenditures are for care given during the last six months of life. The costs to Medicaid programs and private insurance are equally staggering.

But we know that too much of this “care” is futile, hurtful, and wasteful. While some will opt to “do everything” no matter how painful the treatment or how unlikely the chance for recovery, most people do not want to die in this manner.

Advances in medical technology are truly miraculous, and we are reaping their benefits through longer and healthier life spans. But the end comes for everyone, and today more and more Americans are choosing to die at home or in hospice, surrounded by their loved ones.

The medical and legal systems need to be prepared to support that choice.

Care at the end of life raises some deeply personal choices. Who should make them? Doctors? Government? Insurance companies? Hospitals? Ethics committees? Religious institutions?

As both a physician and a legislator, I believe that the operative values should be the patient’s. And the only way to ensure that outcome is through advance directives. When patients haven’t expressed their wishes or designated someone who can act for them if they’re incapacitated, controversy and painful family upheaval can ensue.

Completing advance directives should become as routine as renewing your driver’s license or filing a tax return. If advance directives were to become the norm — if say, 80 percent of adult Americans had them — we’d be offering more personalized and humane care for far less money.

Respecting individual rights is the right way to reduce health care costs.

No clear answers for end-of-life, but conversations can help

By Melissa Flores
Pennlive.com
July 2, 2012

Lisa Krieger’s 88-year-old father, who was suffering from dementia, was very frail when he developed an infection.

“I rushed him to the ER because that’s what you do when you have a sick loved one,” she said.

But Krieger, who writes about health for the San Jose Mercury News, soon learned how difficult end-of-life decisions can be. She was an only child, and deciding how far to go to try to extend her father’s life fell to her.

“It is like being on a freeway of technology where you can’t find the exit ramps,” she said. “I learned the system is built to save people. It is easy to get care and very hard to say no.

“What really resonates is that it is important to have goals and make sure technology use is in line with those goals,” she said.

Such questions about how to approach the end of life, especially for family members or friends making decisions for loved ones with a diminished capacity to make their own choices, can prove full of dilemmas.

The Hospice Foundation of America tries to address some of the issues each year with its “Living With Grief” video presentation, shown at conferences throughout the United States, including a recent conference in Monterey Bay this spring.

The panel discussion that followed the video brought together medical professionals, lawyers and people who have recently faced end-of-life issues.

Even advanced directives – which can include such information as what treatment or procedures a patient wants such as resuscitation, ventilators or feeding tubes – can have limitations since they cannot foresee all possible situations, said John Hausdorff, the medical director of Community Hospital of the Monterey Peninsula’s hospice program.

“What we really need are discussions,” Hausdorff said. “We need to get it to be okay to talk about these things with family at the dinner table and with physicians. It should be more around ‘What do I value?’ and what do you want to be able to do. When things get very bad, maybe that’s the point you let go – when you can’t recognize your family or joke around.”

It’s important for physicians to take care in what kinds of treatment options are offered at the end of life, said Theodore Kaczmar, a neurosurgeon who is on the bioethics committee at Salinas Valley Memorial Hospital.

“We need to ethically distinguish between treatment that has a low chance of success or no chance,” he said. “Certain care options we don’t present to families because it would be futile. It is much harder to withdraw treatment than not to start it.”

Krieger, speaking from a family’s point of view, said that she would have preferred healthcare professionals refer to treatment as ineffective rather than futile because that implies there is no hope.

“Finally when the palliative care team came in (to care for her father) what really helped a whole lot was they said what they can do,” she said. “‘We can’t cure him but we can make him comfortable.’ The way they framed it wasn’t that they were taking care away but that they were providing a different type of care that would be better for him.”

Hausdorff described a patient he had seen once who was 90 years old, had cancer, bad lungs, diabetes, dementia and problems with her legs. The family brought her from a nursing home to the hospital and insisted on CPR even after doctors said she would not be able to survive CPR.

“In homecare we talk with families about end of life – that there is a difference between extending life and delaying death,” said John O’Brien, the chief executive officer of Central Coast Senior Services. “Quite often (family members) are delaying death with what they are talking about but they don’t realize it. They talk about delaying the inevitable but it is going to happen.”

“Medical schools didn’t talk a lot about hospice,” O’Brien said. “Medicine is a world of specialists and they can kick the can down the road to the next physician. The outcome for the family and patient side is lacking…we tend to avoid the conversation.”

Stephen Pearson, a lawyer on the panel, said more education about hospice would help to get people to select it earlier on.

“There needs to be more education about the advantages,” he said.

Hausdorff said as hospice and palliative care programs expand there is a push to teach it in medical schools and with residents.

Krieger acknowledged that it can be hard for families to discuss the topic.

“When someone gets a dementia diagnosis is a good time to talk,” she said. “One thing I keep hearing from people is ‘I thought there would be more time.’”

She said as societal norms change more of these important conversations may start.

“Kids don’t want to talk about it because they don’t want to feel like they are throwing granny off a cliff and parents don’t want to talk about it because it is depressing. But I hope there is a change to the norm so it becomes acceptable.”

When Demented Patients Receive Feeding Tubes

May 9, 2011
By PAULA SPAN
The New York Times

I wrote a few months back about one of the toughest decisions families face as their elders falter: whether to allow insertion of a feeding tube. Somehow, this question seems to stir up even more doubt and anxiety than other medical interventions intended to prolong or improve life. When a senior nears death and cannot speak for herself, we may find it easier to say no to cardiopulmonary resuscitation or a ventilator than to say no to nutrition.

Nourishment, after all, is the way we show love and care from the earliest moments of life. “What happens when you get sick?” said Dr. Joan Teno, a community health physician and researcher at Brown University. “Your mom feeds you.”

So for nursing home residents with advanced dementia, sons and daughters often opt to return the favor — even though the medical consensus is that it’s not a favor. Most dementia patients will eventually develop problems with eating and swallowing as the disease progresses, but feeding them through surgically implanted tubes has not been shown to improve their survival, to prevent pneumonia or heal bedsores, or to improve their quality of life. Nevertheless, about a third of nursing home residents with advanced dementia do receive feeding tubes, usually during a hospitalization.

Dr. Teno’s most recent study, published on May 3 in The Journal of the American Geriatrics Society, goes a long way toward explaining why that happens.

She and Dr. Susan Mitchell of the Hebrew Senior Life Institute for Aging Research, veteran researchers (for 10 long years) into the use of feeding tubes, led a team surveying family members, after their relatives’ deaths, on the decisions they’d made. They interviewed 486 people in five states, two with low rates of feeding tube use (Massachusetts and Minnesota) and three with high rates (Alabama, Florida and Texas).

The fact that some American hospitals inserted no feeding tubes — zero — in patients with advanced dementia over an eight-year period while others intubated one in three, findings from a previous study by these researchers, was a tip-off that something besides medical need was at work.

What emerged from families’ accounts is that the decision process about feeding tubes hardly merits the phrase “informed consent.” Of patients who received feeding tubes, 13.7 percent of family members reported that doctors had inserted the tubes without seeking permission at all. “I just walked in and it was there. Nobody talked to me,” one relative told the interviewer.

This stunned even an old hand like Dr. Teno. “My expectation was, we’ll find there weren’t good discussions,” she told me in an interview. “I wasn’t thinking we’d find there was no discussion.”

But even when medical providers raised the issue and a feeding tube was inserted, 12.6 percent of the family respondents said they had felt pressured by the physician to agree to the procedure, and more than half believed that the physician strongly had favored tube insertion. Moreover, these talks tended to be cursory: More than 40 percent of respondents said the discussion had lasted less than 15 minutes, and roughly a third said no one had mentioned the risks involved.

“We’re falling short of our ideals,” Dr. Teno lamented.

The frequent failure to outline the problems associated with feeding tubes was particularly disturbing, in her view. When demented patients are bothered by their tubes — and almost 40 percent of family members said they had observed signs of distress — they often try to pull out the tubes. “Then they’re given drugs to sedate them, or their hands are tied down,” Dr. Teno said. In this study, where patients’ average age was nearly 88, more than a quarter of those with tubes were restrained, physically or with medication. Tubes can also cause infections, nausea, vomiting and diarrhea.

Why the apparent push for feeding tubes? “My guess is, we’ve changed hospital medicine to focus on discharge,” Dr. Teno said. “How do we move someone quickly out of the system? You put the feeding tube in, you send people back to the nursing home.”

The pressure has less to do with fees, she thought — it’s not particularly expensive to put in a feeding tube, relative to other hospital procedures — than with time. Explaining to families what feeding tubes can and can’t do, answering their questions as they grapple with the decision, takes a lot of that.

(My own theory: It also requires an acknowledgment that advanced dementia is a terminal condition. Too often, doctors still don’t want to talk about death.)

In the end, about a third of these families said they thought the feeding tube did improve their loved ones’ quality of life, while only 23.4 percent said they regretted the use of the tube. Yet Dr. Teno wonders how well those numbers reflect reality.

“We mismanage this final chapter of life, and it can be traumatic for family members,” she said. (She’s also a hospice medical director.) In the aftermath, “people have to make peace with their decisions.”

But perhaps they would have reached different decisions if they’d gotten more information, and more unbiased information, before they had to make them.

What Broke My Father’s Heart

By KATY BUTLER
New York Times Magazine

One October afternoon three years ago while I was visiting my parents, my mother made a request I dreaded and longed to fulfill. She had just poured me a cup of Earl Grey from her Japanese iron teapot, shaped like a little pumpkin; outside, two cardinals splashed in the birdbath in the weak Connecticut sunlight. Her white hair was gathered at the nape of her neck, and her voice was low. “Please help me get Jeff’s pacemaker turned off,” she said, using my father’s first name. I nodded, and my heart knocked.

Upstairs, my 85-year-old father, Jeffrey, a retired Wesleyan University professor who suffered from dementia, lay napping in what was once their shared bedroom. Sewn into a hump of skin and muscle below his right clavicle was the pacemaker that helped his heart outlive his brain. The size of a pocket watch, it had kept his heart beating rhythmically for nearly five years. Its battery was expected to last five more.

After tea, I knew, my mother would help him from his narrow bed with its mattress encased in waterproof plastic. She would take him to the toilet, change his diaper and lead him tottering to the couch, where he would sit mutely for hours, pretending to read Joyce Carol Oates, the book falling in his lap as he stared out the window.

I don’t like describing what dementia did to my father — and indirectly to my mother — without telling you first that my parents loved each other, and I loved them. That my mother, Valerie, could stain a deck and sew an evening dress from a photo in Vogue and thought of my father as her best friend. That my father had never given up easily on anything.

Born in South Africa, he lost his left arm in World War II, but built floor-to-ceiling bookcases for our living room; earned a Ph.D. from Oxford; coached rugby; and with my two brothers as crew, sailed his beloved Rhodes 19 on Long Island Sound. When I was a child, he woke me, chortling, with his gloss on a verse from “The Rubaiyat of Omar Khayyam”: “Awake, my little one! Before life’s liquor in its cup be dry!” At bedtime he tucked me in, quoting “Hamlet” : “May flights of angels sing thee to thy rest!”

Now I would look at him and think of Anton Chekhov, who died of tuberculosis in 1904. “Whenever there is someone in a family who has long been ill, and hopelessly ill,” he wrote, “there come painful moments when all timidly, secretly, at the bottom of their hearts long for his death.” A century later, my mother and I had come to long for the machine in my father’s chest to fail.

Until 2001, my two brothers and I — all living in California — assumed that our parents would enjoy long, robust old ages capped by some brief, undefined final illness. Thanks to their own healthful habits and a panoply of medical advances — vaccines, antibiotics, airport defibrillators, 911 networks and the like — they weren’t likely to die prematurely of the pneumonias, influenzas and heart attacks that decimated previous generations. They walked every day. My mother practiced yoga. My father was writing a history of his birthplace, a small South African town.

In short, they were seemingly among the lucky ones for whom the American medical system, despite its fragmentation, inequity and waste, works quite well. Medicare and supplemental insurance paid for their specialists and their trusted Middletown internist, the lean, bespectacled Robert Fales, who, like them, was skeptical of medical overdoing. “I bonded with your parents, and you don’t bond with everybody,” he once told me. “It’s easier to understand someone if they just tell it like it is from their heart and their soul.”

They were also stoics and religious agnostics. They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.

Things took their first unexpected turn on Nov. 13, 2001, when my father — then 79, pacemakerless and seemingly healthy — collapsed on my parents’ kitchen floor in Middletown, making burbling sounds. He had suffered a stroke.

He came home six weeks later permanently incapable of completing a sentence. But as I’ve said, he didn’t give up easily, and he doggedly learned again how to fasten his belt; to peck out sentences on his computer; to walk alone, one foot dragging, to the university pool for water aerobics. He never again put on a shirt without help or looked at the book he had been writing. One day he haltingly told my mother, “I don’t know who I am anymore.”

His stroke devastated two lives. The day before, my mother was an upper-middle-class housewife who practiced calligraphy in her spare time. Afterward, she was one of tens of millions of people in America, most of them women, who help care for an older family member.

Their numbers grow each day. Thanks to advanced medical technologies, elderly people now survive repeated health crises that once killed them, and so the “oldest old” have become the nation’s most rapidly growing age group. Nearly a third of Americans over 85 have dementia (a condition whose prevalence rises in direct relationship to longevity). Half need help with at least one practical, life-sustaining activity, like getting dressed or making breakfast. Even though a capable woman was hired to give my dad showers, my 77-year-old mother found herself on duty more than 80 hours a week. Her blood pressure rose and her weight fell. On a routine visit to Dr. Fales, she burst into tears. She was put on sleeping pills and antidepressants.

My father said he came to believe that she would have been better off if he had died. “She’d have weeped the weep of a widow,” he told me in his garbled, poststroke speech, on a walk we took together in the fall of 2002. “And then she would have been all right.” It was hard to tell which of them was suffering more.

As we shuffled through the fallen leaves that day, I thought of my father’s father, Ernest Butler. He was 79 when he died in 1965, before pacemakers, implanted cardiac defibrillators, stents and replacement heart valves routinely staved off death among the very old. After completing some long-unfinished chairs, he cleaned his woodshop, had a heart attack and died two days later in a plain hospital bed. As I held my dad’s soft, mottled hand, I vainly wished him a similar merciful death.

A few days before Christmas that year, after a vigorous session of water exercises, my father developed a painful inguinal (intestinal) hernia. My mother took him to Fales, who sent them to a local surgeon, who sent them to a cardiologist for a preoperative clearance. After an electrocardiogram recorded my father’s slow heartbeat — a longstanding and symptomless condition not uncommon in the very old — the cardiologist, John Rogan, refused to clear my dad for surgery unless he received a pacemaker.

Without the device, Dr. Rogan told me later, my father could have died from cardiac arrest during surgery or perhaps within a few months. It was the second time Rogan had seen my father. The first time, about a year before, he recommended the device for the same slow heartbeat. That time, my then-competent and prestroke father expressed extreme reluctance, on the advice of Fales, who considered it overtreatment.

My father’s medical conservatism, I have since learned, is not unusual. According to an analysis by the Dartmouth Atlas medical-research group, patients are far more likely than their doctors to reject aggressive treatments when fully informed of pros, cons and alternatives — information, one study suggests, that nearly half of patients say they don’t get. And although many doctors assume that people want to extend their lives, many do not. In a 1997 study in The Journal of the American Geriatrics Society, 30 percent of seriously ill people surveyed in a hospital said they would “rather die” than live permanently in a nursing home. In a 2008 study in The Journal of the American College of Cardiology, 28 percent of patients with advanced heart failure said they would trade one day of excellent health for another two years in their current state.

When Rogan suggested the pacemaker for the second time, my father was too stroke-damaged to discuss, and perhaps even to weigh, his trade­offs. The decision fell to my mother — anxious to relieve my father’s pain, exhausted with caregiving, deferential to doctors and no expert on high-tech medicine. She said yes. One of the most important medical decisions of my father’s life was over in minutes. Dr. Fales was notified by fax.

Fales loved my parents, knew their suffering close at hand, continued to oppose a pacemaker and wasn’t alarmed by death. If he had had the chance to sit down with my parents, he could have explained that the pacemaker’s battery would last 10 years and asked whether my father wanted to live to be 89 in his nearly mute and dependent state. He could have discussed the option of using a temporary external pacemaker that, I later learned, could have seen my dad safely through surgery. But my mother never consulted Fales. And the system would have effectively penalized him if she had. Medicare would have paid him a standard office-visit rate of $54 for what would undoubtedly have been a long meeting — and nothing for phone calls to work out a plan with Rogan and the surgeon.

Medicare has made minor improvements since then, and in the House version of the health care reform bill debated last year, much better payments for such conversations were included. But after the provision was distorted as reimbursement for “death panels,” it was dropped. In my father’s case, there was only a brief informed-consent process, covering the boilerplate risks of minor surgery, handled by the general surgeon.

I believe that my father’s doctors did their best within a compartmentalized and time-pressured medical system. But in the absence of any other guiding hand, there is no doubt that economics helped shape the wider context in which doctors made decisions. Had we been at the Mayo Clinic — where doctors are salaried, medical records are electronically organized and care is coordinated by a single doctor — things might have turned out differently. But Middletown is part of the fee-for-service medical economy. Doctors peddle their wares on a piecework basis; communication among them is haphazard; thinking is often short term; nobody makes money when medical interventions are declined; and nobody is in charge except the marketplace.

And so on Jan. 2, 2003, at Middlesex Hospital, the surgeon implanted my father’s pacemaker using local anesthetic. Medicare paid him $461 and the hospital a flat fee of about $12,000, of which an estimated $7,500 went to St. Jude Medical, the maker of the device. The hernia was fixed a few days later.

It was a case study in what primary-care doctors have long bemoaned: that Medicare rewards doctors far better for doing procedures than for assessing whether they should be done at all. The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way.

Last year, doctors, hospitals, drug companies, medical-equipment manufacturers and other medical professionals spent $545 million on lobbying, according to the Center for Responsive Politics. This may help explain why researchers estimate that 20 to 30 percent of Medicare’s $510 billion budget goes for unnecessary tests and treatment. Why cost-containment received short shrift in health care reform. Why physicians like Fales net an average of $173,000 a year, while noninvasive cardiologists like Rogan net about $419,000.

The system rewarded nobody for saying “no” or even “wait” — not even my frugal, intelligent, Consumer-Reports-reading mother. Medicare and supplemental insurance covered almost every penny of my father’s pacemaker. My mother was given more government-mandated consumer information when she bought a new Camry a year later.

And so my father’s electronically managed heart — now requiring frequent monitoring, paid by Medicare — became part of the $24 billion worldwide cardiac-device industry and an indirect subsidizer of the fiscal health of American hospitals. The profit margins that manufacturers earn on cardiac devices is close to 30 percent. Cardiac procedures and diagnostics generate about 20 percent of hospital revenues and 30 percent of profits.

Shortly after New Year’s 2003, my mother belatedly called and told me about the operations, which went off without a hitch. She didn’t call earlier, she said, because she didn’t want to worry me. My heart sank, but I said nothing. It is one thing to silently hope that your beloved father’s heart might fail. It is another to actively abet his death.

The pacemaker bought my parents two years of limbo, two of purgatory and two of hell. At first they soldiered on, with my father no better and no worse. My mother reread Jon Kabat-Zinn’s “Full Catastrophe Living,” bought a self-help book on patience and rose each morning to meditate.

In 2005, the age-related degeneration that had slowed my father’s heart attacked his eyes, lungs, bladder and bowels. Clots as narrow as a single human hair lodged in tiny blood vessels in his brain, killing clusters of neurons by depriving them of oxygen. Long partly deaf, he began losing his sight to wet macular degeneration, requiring ocular injections that cost nearly $2,000 each. A few months later, he forgot his way home from the university pool. He grew incontinent. He was collapsing physically, like an ancient, shored-up house.

In the summer of 2006, he fell in the driveway and suffered a brain hemorrhage. Not long afterward, he spent a full weekend compulsively brushing and rebrushing his teeth. “The Jeff I married . . . is no longer the same person,” my mother wrote in the journal a social worker had suggested she keep. “My life is in ruins. This is horrible, and I have lasted for five years.” His pacemaker kept on ticking.

When bioethicists debate life-extending technologies, the effects on people like my mother rarely enter the calculus. But a 2007 Ohio State University study of the DNA of family caregivers of people with Alzheimer’s disease showed that the ends of their chromosomes, called telomeres, had degraded enough to reflect a four-to-eight-year shortening of lifespan. By that reckoning, every year that the pacemaker gave my irreparably damaged father took from my then-vigorous mother an equal year.

When my mother was upset, she meditated or cleaned house. When I was upset, I Googled. In 2006, I discovered that pacemakers could be deactivated without surgery. Nurses, doctors and even device salesmen had done so, usually at deathbeds. A white ceramic device, like a TV remote and shaped like the wands that children use to blow bubbles, could be placed around the hump on my father’s chest. Press a few buttons and the electrical pulses that ran down the leads to his heart would slow until they were no longer effective. My father’s heart, I learned, would probably not stop. It would just return to its old, slow rhythm. If he was lucky, he might suffer cardiac arrest and die within weeks, perhaps in his sleep. If he was unlucky, he might linger painfully for months while his lagging heart failed to suffuse his vital organs with sufficient oxygenated blood.

If we did nothing, his pacemaker would not stop for years. Like the tireless charmed brooms in Disney’s “Fantasia,” it would prompt my father’s heart to beat after he became too demented to speak, sit up or eat. It would keep his heart pulsing after he drew his last breath. If he was buried, it would send signals to his dead heart in the coffin. If he was cremated, it would have to be cut from his chest first, to prevent it from exploding and damaging the walls or hurting an attendant.

On the Internet, I discovered that the pacemaker — somewhat like the ventilator, defibrillator and feeding tube — was first an exotic, stopgap device, used to carry a handful of patients through a brief medical crisis. Then it morphed into a battery-powered, implantable and routine treatment. When Medicare approved the pacemaker for reimbursement in 1966, the market exploded. Today pacemakers are implanted annually in more than 400,000 Americans, about 80 percent of whom are over 65. According to calculations by the Dartmouth Atlas research group using Medicare data, nearly a fifth of new recipients who receive pacemakers annually — 76,000 — are over 80. The typical patient with a cardiac device today is an elderly person suffering from at least one other severe chronic illness.

Over the years, as technology has improved, the battery life of these devices lengthened. The list of heart conditions for which they are recommended has grown. In 1984, the treatment guidelines from the American College of Cardiology declared that pacemakers were strongly recommended as “indicated” or mildly approved as “reasonable” for 56 heart conditions and “not indicated” for 31 more. By 2008, the list for which they were strongly or mildly recommended expanded to 88, with most of the increase in the lukewarm “reasonable” category.

The research backing the expansion of diagnoses was weak. Over all, only 5 percent of the positive recommendations were supported by research from multiple double-blind randomized studies, the gold standard of evidence-based medicine. And 58 percent were based on no studies at all, only a “consensus of expert opinion.” Of the 17 cardiologists who wrote the 2008 guidelines, 11 received financing from cardiac-device makers or worked at institutions receiving it. Seven, due to the extent of their financial connections, were recused from voting on the guidelines they helped write.

This pattern — a paucity of scientific support and a plethora of industry connections — holds across almost all cardiac treatments, according to the cardiologist Pierluigi Tricoci of Duke University’s Clinical Research Institute. Last year in The Journal of the American Medical Association, Tricoci and his co-authors wrote that only 11 percent of 2,700 widely used cardiac-treatment guidelines were based on that gold standard. Most were based only on expert opinion.

Experts are as vulnerable to conflicts of interest as researchers are, the authors warned, because “expert clinicians are also those who are likely to receive honoraria, speakers bureau [fees], consulting fees or research support from industry.” They called the current cardiac-research agenda “strongly influenced by industry’s natural desire to introduce new products.”

Perhaps it’s no surprise that I also discovered others puzzling over cardiologists who recommended pacemakers for relatives with advanced dementia. “78-year-old mother-in-law has dementia; severe short-term memory issues,” read an Internet post by “soninlaw” on Elderhope.com, a caregivers’ site, in 2007. “On a routine trip to her cardiologist, doctor decides she needs a pacemaker. . . . Anyone have a similar encounter?”

By the summer of 2007, my dad had forgotten the purpose of a dinner napkin and had to be coached to remove his slippers before he tried to put on his shoes. After a lifetime of promoting my father’s health, my mother reversed course. On a routine visit, she asked Rogan to deactivate the pacemaker. “It was hard,” she later told me. “I was doing for Jeff what I would have wanted Jeff to do for me.” Rogan soon made it clear he was morally opposed. “It would have been like putting a pillow over your father’s head,” he later told me.

Not long afterward, my mother declined additional medical tests and refused to put my father on a new anti-dementia drug and a blood thinner with troublesome side effects. “I take responsibility for whatever,” she wrote in her journal that summer. “Enough of all this overkill! It’s killing me! Talk about quality of life — what about mine?”

Then came the autumn day when she asked for my help, and I said yes. I told myself that we were simply trying to undo a terrible medical mistake. I reminded myself that my dad had rejected a pacemaker when his faculties were intact. I imagined, as a bioethicist had suggested, having a 15-minute conversation with my independent, predementia father in which I saw him shaking his head in horror over any further extension of what was not a “life,” but a prolonged and attenuated dying. None of it helped. I knew that once he died, I would dream of him and miss his mute, loving smiles. I wanted to melt into the arms of the father I once had and ask him to handle this. Instead, I felt as if I were signing on as his executioner and that I had no choice.

Over the next five months, my mother and I learned many things. We were told, by the Hemlock Society’s successor, Compassion and Choices, that as my father’s medical proxy, my mother had the legal right to ask for the withdrawal of any treatment and that the pacemaker was, in theory at least, a form of medical treatment. We learned that although my father’s living will requested no life support if he were comatose or dying, it said nothing about dementia and did not define a pacemaker as life support. We learned that if we called 911, emergency medical technicians would not honor my father’s do-not-resuscitate order unless he wore a state-issued orange hospital bracelet. We also learned that no cardiology association had given its members clear guidance on when, or whether, deactivating pacemakers was ethical.

(Last month that changed. The Heart Rhythm Society and the American Heart Association issued guidelines declaring that patients or their legal surrogates have the moral and legal right to request the withdrawal of any medical treatment, including an implanted cardiac device. It said that deactivating a pacemaker was neither euthanasia nor assisted suicide, and that a doctor could not be compelled to do so in violation of his moral values. In such cases, it continued, doctors “cannot abandon the patient but should involve a colleague who is willing to carry out the procedure.” This came, of course, too late for us.)

In the spring of 2008, things got even worse. My father took to roaring like a lion at his caregivers. At home in California, I searched the Internet for a sympathetic cardiologist and a caregiver to put my Dad to bed at night. My frayed mother began to shout at him, and their nighttime scenes were heartbreaking and frightening. An Alzheimer’s Association support-group leader suggested that my brothers and I fly out together and institutionalize my father. This leader did not know my mother’s formidable will and had never heard her speak about her wedding vows or her love.

Meanwhile my father drifted into what nurses call “the dwindles”: not sick enough to qualify for hospice care, but sick enough to never get better. He fell repeatedly at night and my mother could not pick him up. Finally, he was weak enough to qualify for palliative care, and a team of nurses and social workers visited the house. His chest grew wheezy. My mother did not request antibiotics. In mid-April 2008, he was taken by ambulance to Middlesex Hospital’s hospice wing, suffering from pneumonia.

Pneumonia was once called “the old man’s friend” for its promise of an easy death. That’s not what I saw when I flew in. On morphine, unreachable, his eyes shut, my beloved father was breathing as hard and regularly as a machine.

My mother sat holding his hand, weeping and begging for forgiveness for her impatience. She sat by him in agony. She beseeched his doctors and nurses to increase his morphine dose and to turn off the pacemaker. It was a weekend, and the doctor on call at Rogan’s cardiology practice refused authorization, saying that my father “might die immediately.” And so came five days of hard labor. My mother and I stayed by him in shifts, while his breathing became increasingly ragged and his feet slowly started to turn blue. I began drafting an appeal to the hospital ethics committee. My brothers flew in.

On a Tuesday afternoon, with my mother at his side, my father stopped breathing. A hospice nurse hung a blue light on the outside of his hospital door. Inside his chest, his pacemaker was still quietly pulsing.

After his memorial service in the Wesleyan University chapel, I carried a box from the crematory into the woods of an old convent where he and I often walked. It was late April, overcast and cold. By the side of a stream, I opened the box, scooped out a handful of ashes and threw them into the swirling water. There were some curious spiraled metal wires, perhaps the leads of his pacemaker, mixed with the white dust and pieces of bone.

A year later, I took my mother to meet a heart surgeon in a windowless treatment room at Brigham and Women’s Hospital in Boston. She was 84, with two leaking heart valves. Her cardiologist had recommended open-heart surgery, and I was hoping to find a less invasive approach. When the surgeon asked us why we were there, my mother said, “To ask questions.” She was no longer a trusting and deferential patient. Like me, she no longer saw doctors — perhaps with the exception of Fales — as healers or her fiduciaries. They were now skilled technicians with their own agendas. But I couldn’t help feeling that something precious — our old faith in a doctor’s calling, perhaps, or in a healing that is more than a financial transaction or a reflexive fixing of broken parts — had been lost.

The surgeon was forthright: without open-heart surgery, there was a 50-50 chance my mother would die within two years. If she survived the operation, she would probably live to be 90. And the risks? He shrugged. Months of recovery. A 5 percent chance of stroke. Some possibility, he acknowledged at my prompting, of postoperative cognitive decline. (More than half of heart-bypass patients suffer at least a 20 percent reduction in mental function.) My mother lifted her trouser leg to reveal an anklet of orange plastic: her do-not-resuscitate bracelet. The doctor recoiled. No, he would not operate with that bracelet in place. It would not be fair to his team. She would be revived if she collapsed. “If I have a stroke,” my mother said, nearly in tears, “I want you to let me go.” What about a minor stroke, he said — a little weakness on one side?

I kept my mouth shut. I was there to get her the information she needed and to support whatever decision she made. If she emerged from surgery intellectually damaged, I would bring her to a nursing home in California and try to care for her the way she had cared for my father at such cost to her own health. The thought terrified me.

The doctor sent her up a floor for an echocardiogram. A half-hour later, my mother came back to the waiting room and put on her black coat. “No,” she said brightly, with the clarity of purpose she had shown when she asked me to have the pacemaker deactivated. “I will not do it.”

She spent the spring and summer arranging house repairs, thinning out my father’s bookcases and throwing out the files he collected so lovingly for the book he never finished writing. She told someone that she didn’t want to leave a mess for her kids. Her chest pain worsened, and her breathlessness grew severe. “I’m aching to garden,” she wrote in her journal. “But so it goes. ACCEPT ACCEPT ACCEPT.”

Last August, she had a heart attack and returned home under hospice care. One evening a month later, another heart attack. One of my brothers followed her ambulance to the hospice wing where we had sat for days by my father’s bed. The next morning, she took off her silver earrings and told the nurses she wanted to stop eating and drinking, that she wanted to die and never go home. Death came to her an hour later, while my brother was on the phone to me in California — almost as mercifully as it had come to my paternal grandfather. She was continent and lucid to her end.

A week later, at the same crematory near Long Island Sound, my brothers and I watched through a plate-glass window as a cardboard box containing her body, dressed in a scarlet silk ao dai she had sewn herself, slid into the flames. The next day, the undertaker delivered a plastic box to the house where, for 45 of their 61 years together, my parents had loved and looked after each other, humanly and imperfectly. There were no bits of metal mixed with the fine white powder and the small pieces of her bones.

Katy Butler lives in Mill Valley, Calif., and teaches memoir writing at the Esalen Institute in Big Sur.

Find Yourself a Good Hospital

Since November, when the United States Council of Catholic Bishops (USCCB) voted to change the Ethical and Religious Directives for Catholic Health Care, I have written frequently how the new policy could result in continued tube feeding for thousands of unconscious and severely demented patients in Catholic hospitals and nursing homes. Newly released research highlights the problem.

Representatives for Catholic hospitals downplay it. Sister Carol Keehan, executive director of the Catholic Health Association, said she doesn’t see much conflict between patients’ and families’ end-of-life wishes and the new directive. “Advance directives are held in great respect in Catholic hospitals,” she said in a recent interview. “Some might like to say there’s a terrible problem, but there isn’t.”

Catholic hospitals have attracted unwanted attention over this change in policy, and they assert the attention is unwarranted, because mentally compromised patients are in nursing homes, not hospitals. Alan Sanders, director for the Center for Ethics at St. Joseph’s Hospital in Atlanta, says that as an acute care facility, St. Joseph’s is unlikely to encounter a decision to remove a feeding tube from a patient in a persistent vegetative state.

Well, not exactly. Recent evidence indicates hospitals, not nursing homes, are the usual site of decisions to insert feeding tubes. A 2003 study reported more than one-third of nursing home residents with advanced dementia have a feeding tube, and a new study shows whether they get one depends much on the hospital they’re admitted to. The Providence Journal reports,

Dr. Joan M. Teno, the chief author of the study, said the results show that it’s not the wishes of the patients that are driving these decisions. “It really is the hospital culture that is determining this…. This doesn’t look like a process that is respecting patient choice.”

Hospitals vary widely in their incidence of feeding tube insertion. Even hospitals in the same community can differ greatly in how often they place a feeding tube in demented patients. In spite of evidence proving the tubes increase suffering and do not prolong life, some hospitals have even increased their utilization in recent years.

The survey of more than a quarter-million hospital admissions from 2000 to 2007 showed that during the last two years of the survey, Roger Williams Medical Center and Kent Hospital stopped using the tubes.

Nationally, 12 percent of the hospitals fell into the same category.

But at St. Joseph Health Services of Rhode Island, which runs St. Joseph Hospital and Our Lady of Fatima Hospital, use of the feeding tubes actually increased during the last two years of study – 7.7 percent of patients got them, up from 6.9 percent during the broader period of 2000 to 2007.

That’s more than the national rate of 6.2 percent in 2007, an average that has been declining since 2000.

Teno said that within the past year, U.S. bishops decreed that feeding tubes must be given for all patients – Catholic and non-Catholic – who have lost the ability to eat or drink, unless they are actually close to death.

That philosophy, “I think, partially explains the results with St. Joe’s, being a Catholic health-care system,” said Teno.

The study illuminates other factors influencing feeding tube insertion. 

For-profit hospitals and larger hospitals were more likely to use the tubes, Teno and her colleagues found. Black and Hispanic patients were nearly twice as likely to get them as whites.

Teno said she is concerned that Catholic hospitals may be trying to override the wishes of patients when they insist on feeding tubes.

Advance care planning, the study says, also has an important role in reduction of potentially unnecessary procedures. Although it’s not fool-proof (590 patients were given feeding tubes despite written orders to forgo artificial hydration and nutrition!) patients with a living will and durable power of attorney for health care were far less likely to have tubes inserted.

Once again, our advice proves sound: prepare an advance directive, talk to your doctor, talk to your loved ones. Because you can’t be sure whether the policies of a for-profit hospital, or a Catholic one, might impose an unwanted feeding tube, consider adding this Sectarian Health Care Directive addendum. And help Compassion & Choices set enforceability standards for advance directives. We want feeding tube decisions to follow your wishes, not institutional policies of profit or doctrine.