I had a friend who was a bioethicist at Harvard medical school, and the pro euthanasia clique there routinely ridiculed his conservative writings. It was so bad that he rarely socialized when he wasn’t working (they couldn’t fire him: He had tenure).

That was twenty years ago. For awhile, the Politically correct death people had control of every major medical journal: I was living in Boston at the time, and The New England Journal kept publishing articles pro and con euthanasia, but with one thing in common: They all said: Well, after all, the Netherlands prove that euthanasia can be legalized and controlled. And every time they published that statement, I would point out that the numbers in various reports varied greatly, and this suggested no regulation was being done despite their claim. But since I was a lowly resident at the time, none of my letters raising technical questions about the data irregularities were published.

What stopped the farce by these elitist to legalize euthanasia wereseveral things: One, a Lancet article showed that a lot of unrequested euthanasia was being done in the Netherlands, and that most cases weren’t reported, so the regulation part was a farce.

The second thing was the scariness of Jack Kavorkian…despite a sympathetic press, he still looked like a vampire.

But the third thing that stopped them was that their intended victims started giving them a hard time.

Give a lecture on compassionate ending of life (and nearly all advocates are on record saying that such deaths will start with the terminally ill but eventually it will be available for the senile and handicapped), and voila: you’d find a cripple beating down your door and shouting murderer at you.

So back to the slippery slope, guys. Let’s not pretend our agenda includes the whole range of death on demand for all sorts of folks. Let’s go slowly.

Hence we see this “study” from Harvard Medical school, summarized in the Boston papers, which stands the words “care” and “compassion” on their head: Caring for someone will mean not giving even normal ordinary care– in this case, antibiotics, to someone who is moderately senile.

The disturbing part is not the study itself (which I discuss below) but the accompanying editorial written by two physicians from the Tel Aviv Medical Center.

“If there is no benefit to the individual patient, the good of the public health demands that antibiotic use be withheld,” they write. “We must … begin to consider every decision to use antibiotics in this population as we would decisions regarding other treatment modalities, including resuscitation and major surgery.”

So shame on those who try to treat patients trying to save their lives: They (not the tens of millions of people treated for colds with antibiotics) are the cause of the rising rate of antibiotic resistance.

In contrast, the growth of antibiotic resistance has been widely documented, especially in long-term care settings. Because antibiotic exposure is the greatest risk factor for antibiotic resistance, Mitchell said, treating dying dementia patients with antibiotics may promote resistance.

But the whole article is a chilling example of the slippery slope: first they came for the comatose, then they came for the “vegetative”, then for the “minimally responsive” state (the Terry Schiavo case was called “comatose” in the press, but my experience with the brain damaged makes me think she was in this category) and now, to the mildly but non terminal senile elderly.
And it sounds so logical: Let’s not treat grandmom with antibiotics.

Fevers and infections are common in people at this stage of dementia, creating an opportunity for families to be counseled ahead of time about their goals for care of their loved one at the end of this terminal disease, Mitchell said. If comfort is the key, symptoms of pneumonia, the most common infection, can be eased by oxygen or Tylenol, she said. If postponing death is the hope, there is little in the medical literature to say that antibiotics help extend life.

Really? Nothing in the medical literature to say antibiotics help extend life? But of course when we treat a patient, we do a lot more than give them antibiotics.

When a frail elderly person has pneumonia, the real problem may not be infection per se, but dehydration leading to thick secretions that can’t be coughed up. (Often the problem is not merely aspiration pneumonia, but atelectasis and retention of secretions with secondary infection). Just giving an antibiotic isn’t enough.

What makes the big difference is nursing care: careful feeding by mouth of fluids to prevent dehydration, helping the patients to cough up secretions, repositioning them for comfort (and to prevent bedsores) is the treatment, and may be more valuable than antibiotics. In fact, for patients of any age with atelectasis, there is little proof antibiotics alone (without “pulmonary toilet” to clear the secretions) helps.

Reality check please. If a doctor says: “Don’t treat Mrs. X with antibiotics”. The staff hears “Don’t treat Mrs X”. So she doesn’t get all that time consuming nursing care that would save her life.

The dirty little secret about nursing homes is that they often underpay and overwork staff.

It is just human nature for nurses and especially for semi trained caretakers who are overworked and underpaid to spend less time with those patients who will die anyway, or who are unpleasant to care for, or are senile. And patients not cared for have a higher death rate.

You want to save the patient? Spend money on hands on nursing that saves lives instead of antibiotics.
Indeed, if you have a good staff, the patient is less likely to get sick. Having an RN spend a half hour a day with a resident in a nursing home versus less than ten minutes leads to less hospitalizations (6% vs 18%), fewer urinary infections (10% vs 20%), and less decline in their ability to think (15% VS 30%).

Most of my medical career in the US has been working with minorities, and discussing ending unnecessary and futile treatment can be a delicate matter, since a lot of minority patients refuse to sign “end of life” decisions (1) for fear of not receiving treatment. Too often the elites see this as a problem to be solved, not as an ethical choice:

White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p

This is partly cultural, but a lot of it is fear of racism.Blacks and American indians may see signing a DNR order as allowing staff to let them die when they might otherwise live. The Tuskeegee study, where “non treatment” of syphillis led to black men dying, and the Red Lake study, where non treatment of a strain of glomerulonephritis causing strep led to renal failure in at least six tribal members, show that such worries are not merely due to paranoia.But no matter, insists the writers, we’ll keep bringing up the subject until they sign:

To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care.

Translation: We need to pressure them to sign a DNR/ living will paper so they can die in peace. The writers would never chose to live a life impaired and useless, so obviously they can’t see how anyone might have another opinion.

But my Native American patients would say that the Great Spirit gave them a path to travel, and life and death is his decision. Suffering may be part of that path they are supposed to travel, and stoic dignity and wisdom in old age and illness is one reason the elderly are respected.

Ironically, they often refused extraordinary treatment (such as dialysis or amputation or feeding tubes) but rarely could we have them sign a DNR paper(do not resusitate)…and after one of our contract Emergency Room doctors saw a DNR on her chart so let a nursing home patient choke to death rather than “resusitate” her, we docs stopped pushing. Maybe the patients were wise in their decision.
Despite the perception one gets from the media that American society only admires fame, money, and skills, fifty million people sacrifice time, money and often careers to care for loved ones. As a doctor, I have spent a lot of time as a doctor discussing end of life care with patients–and usually with their extended families. There is a very large gray area in which individuals may decide about treatment versus not treating, and this includes an emphasis on not prolonging suffering as opposed to prolonging life a short time.

For those with Alzheimers, intervening early with outside help (family and neigbors, home health care, respite care) to prevent caretaker burnout helps, as does arranging placement in a local nursing home that is close enough for family to visit instead of waiting until things get so bad that she needs emergency placement halfway across town, where visiting will be difficult.
Yes, I know all those stories about granny being dumped by unloving kids, but I just haven’t met that many of them. Guilt is much more common.

As for end of life care, usually I recommend a paper designating the one who you trust to make such decisions. Make sure they are strong enough to fight for your wishes: In the past, this meant stopping a lot of extraordinary treatment that prolonged death, but remember, in the near future (especially if the government takes over health care) you may need someone strong enough to insist you get treatment, especially the critical hands on nursing treatment when you are in a health care facility.

Because if the Harvard study is going to be the norm, we all may be in danger.

In case you are wondering, this is not merely about ethics. It’s about money.

This JAMA article admits:

The cost difference between intervention and control groups was consistent across all pairs of homes and was statistically significant, suggesting that we observed a true effect of systematic implementation of advance directives. ….Systematic application of LMD (advanced directive) in nursing homes can reduce costs substantially by reducing hospitalizations.

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Note: The server was down when I posted this, so I was unable to check the post for syntax.

The quotations are now indented to clarify the quotes. Sorry about the confusion.

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at Hey Doc Xanga Blog.

1. Palliat Support Care. 2008 Mar;6(1):21-7.Click here to read

2J Palliat Med. 2004 Dec;7(6):808-16.Click here to read

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