May 20, 2011
Lying on the backboard, a frail little old lady moaned with discomfort. She had fallen beside her bed in the nursing home and was then tightly bound by straps onto the backboard, a cervical collar pushing her chin up and holding her immobile. A person not familiar with modern medicine might think the ensemble looked like a torture device. Indeed, it can be. Not only uncomfortable, a backboard is made of hard plastic and can quickly cause pressure ulcers even in younger patients. It’s all too common a scene.
Looking at her, I thought about all of the confused, weak, elderly patients subjected to aggressive care and why it happens. They don’t come to us merely due to the vagaries of age, gravity, and balance. They are sent to us because of the confusing way we mix medicine with legality, anxiety, and unexamined expectations.
If the 95-year-old Alzheimer’s patient has a cervical spine fracture, will we subject him to surgery? When the 80-year-old woman with multi-infarct dementia has a thoracic spine fracture, will the surgeons intervene? And if a lucid 100-year-old man has a brain hemorrhage, will he be whisked off to the operating room so neurosurgeons can drill a hole in his skull?
We are actually being cruel, and we neglect common sense and kindness, when nursing homes send their patients to the emergency department for extensive (and expensive) evaluations of marginally treatable conditions.
In our fragmented treatment algorithms for the elderly, injuries aren’t the only problems. Will the end-stage emphysema patient, diagnosed with pneumonia, be placed on a ventilator for more sustained misery? Will the patient bedridden and confused from multiple strokes benefit from a coronary stent if her chest pain is due to a heart attack? These are reasonable questions, both ethical and economic”especially since most Medicare dollars are spent in the last months of life.
It seems there is an endless tug of war when physicians are dealing with many of our elderly citizens, particularly those who can’t contribute their own opinions to the decision-making process. Largely because the government refuses to address tort reform, elderly patients” frail bodies and hazy minds are endlessly subjected to tests and therapies that add little enjoyment to their lives and probably less to meaningfully extending those lives.