When I am feeling self-assured, I can contend that aging is not a disease we can treat, that death is unavoidable, and that with even the most extreme efforts, crises at the end of life are often inevitable.
No one can control the ending. You sat at this patients bed and had a discussion that shows the respectful relationship you have, that is the win right there doctor.
Nothwithstanding that we all want the most peaceful and gentle passing for ourselves and our family- we are animals with a transition to aging and death that is unavoidable and doesn't necessarily follow that path sadly and that is scary.
I know that I am simplifying what is very difficult for caring family, practitioners and caregivers who are trying very hard to allow for a gentle and respectful passing- for sure. But I think if we eliminate or at least try to decrease the background noise of ageism that is making billions and instead respect the person who is transitioning along a path thst is definitely not new.
Thank you for this excellent article. As a retired occupational therapist with about 40 years of experience, when I was practicing in home health I had many patients who were adamant that they wanted to stay in their homes, and their families were adamant they should go to assisted living. When we discussed that the reality of assisted living is that staff is not necessarily present at all times, so the patient can still fall. The bottom line really becomes how long will they be on the floor before they are found. Although cameras are an invasion of privacy, some families decided they would use cameras so that they could monitor their loved one, have improved peace of mind to allow their loved one to stay in their home. This was often very successful until the patient did require the level of care requiring 1-1 assist when their loved one was transferring or ambulating.
this is the norm in my practice. And like you i wonder each time about this: "Sometimes I think my practice reflects my understanding of the small absolute benefit of many of our interventions, as well as the wisdom I have gained over decades of practice. Other times, I think my practice reflects clinical inertia and fatigue, borne of decades of clinical work." Can i respect autonomy whilst being a more effective salesperson for the "safer route'? Somehow I dont think so...
I don't think you could post something similar to this post too many times. In all my years of nursing I have never known someone wanting to go to rehab and liking it and participating in it. I've known people and family members refuse to go or go and refuse to participate. I've known people being bullied into going and die there.
I wish there were something like a medical alert bracelet that patients can wear all the time that says, "I heard my doctor, I understood what he said, I am choosing to ignore his advice and live my own life".
Over the years I've learned that my advice based on my up-to-date medical knowledge doesn't amount to a hill of beans. The best I can do is educate people so when they do make a decision it is made with understanding of both sides. This will _____, and that will _____ .
As I enter the world of 'senior citizenship' my need to control as much of my life as possible is paramount. Aging takes away a little bit of autonomy every day so let us live and die by our own decisions
Do you mean he dies before his next trip to ER or that he has 4 more trips to ER before he dies? For my money & life, 4 more ER trips before dying would be thaw bad ending
Sign of a good life and likely many good decisions. Staying out of hospitals as much as feasible is also a good life skill to have. 97 and still able to make his own decisions, live as he wants, go for walks, talk to his niece everyday. Pray that every good person should be so fortunate.
You accede to the patients wishes to be treated less aggressively. So did I before retiring. What other choice do you have, other than discharge them or commit them as insane? But what about the patient that wants unjustified testing or procedures? You don't accede to them readily, do you?
I remember having a realization at some point, early on in being an attending, that I simply couldn't make my patients do anything. They had to want it. And not only was I incapable of forcing them, I wasn't sure I wanted to force them, anyway.
I still stand by radical bodily autonomy as a core principle of medicine. But it does open up big questions - what is the purpose of the doctor? What role can and should I play? And as patients get more access to information online - often the exact same information I have access to - I grapple with what role we doctors play, at all.
I think this patient's story already has a happy ending. First, being able to understand and articulate his preferences speaks to the quality of care he has received up to this point, as well as of being in an optimal psychological state. He is given the gift of autonomy, one that we all deserve as human beings. He alone knows what constitutes a "good ending" for himself, and he chose it. Bravo to you for not browbeating him. We should all be so fortunate to outlive the actuarial tables and have such choices in our waning days.
I doubt it! Dr. Cifu's patient has already made it to age 97 with independence, far more than almost all Americans, and putting him amongst the top 0.001 percentile on the planet. Only some trees, and many lies and racist beliefs have a longer average lifespan.
A bad ending is happening daily in Gaza, South Sudan, Ukraine, all over Africa and even to young people dying prematurely in North America. In Toronto, Canada, a sweet 8 y/o boy was killed by a stray bullet last week.
Meanwhile in rich countries, many people are lingering for years in states of complete dependence, no longer recognizable as the complete and often wonderful human beings they once were.
I take Dr. Cifu's posting as parable, with a taste of Jonathan Swift. And I'm looking forward to meeting him at the Preventing Overdiagnosis conference in Oxford a couple of weeks from now.
I found recently that reading Stefan Zweig: The World of Yesterday (published 1942) helped put many modern conundrums in context - including how easily and rapidly advanced civilizations lose freedom and collapse into barbarism. Many readers would recognize not only echos, but premonitions about where we are all being dragged in 2025.
Tom Perry MD (general internist, clinical pharmacologist)
It may pose an even harder challenge for those of us without children or young family to check in on us. Technology will help, we'll see when and if I make it to be old enough to need help.
The other angle I see is that of course seniors want to stay in the home they have always been in but they are too often a home that could house a whole family but is just housing the one person for years or decades. There should really be more options for downsizing without moving so far from the place you've lived.
As a car guy, you should give more love to The French Connection. In the GOAT discussion for best car chase scene ever. 😉
I’m always impressed by your caring and humanity. However, I do fall back on patient autonomy. If a patient is competent, and understands his choices…well, choices have consequences, and patients are entitled to them.
But I do acknowledge another level of discussion about societal/health care costs, which may have disparate implications in different healthcare systems.
No one can control the ending. You sat at this patients bed and had a discussion that shows the respectful relationship you have, that is the win right there doctor.
And I forgot to mention- I feel that we need to eliminate the word frailty.
Nothwithstanding that we all want the most peaceful and gentle passing for ourselves and our family- we are animals with a transition to aging and death that is unavoidable and doesn't necessarily follow that path sadly and that is scary.
I know that I am simplifying what is very difficult for caring family, practitioners and caregivers who are trying very hard to allow for a gentle and respectful passing- for sure. But I think if we eliminate or at least try to decrease the background noise of ageism that is making billions and instead respect the person who is transitioning along a path thst is definitely not new.
Thank you for this excellent article. As a retired occupational therapist with about 40 years of experience, when I was practicing in home health I had many patients who were adamant that they wanted to stay in their homes, and their families were adamant they should go to assisted living. When we discussed that the reality of assisted living is that staff is not necessarily present at all times, so the patient can still fall. The bottom line really becomes how long will they be on the floor before they are found. Although cameras are an invasion of privacy, some families decided they would use cameras so that they could monitor their loved one, have improved peace of mind to allow their loved one to stay in their home. This was often very successful until the patient did require the level of care requiring 1-1 assist when their loved one was transferring or ambulating.
this is the norm in my practice. And like you i wonder each time about this: "Sometimes I think my practice reflects my understanding of the small absolute benefit of many of our interventions, as well as the wisdom I have gained over decades of practice. Other times, I think my practice reflects clinical inertia and fatigue, borne of decades of clinical work." Can i respect autonomy whilst being a more effective salesperson for the "safer route'? Somehow I dont think so...
I don't think you could post something similar to this post too many times. In all my years of nursing I have never known someone wanting to go to rehab and liking it and participating in it. I've known people and family members refuse to go or go and refuse to participate. I've known people being bullied into going and die there.
I wish there were something like a medical alert bracelet that patients can wear all the time that says, "I heard my doctor, I understood what he said, I am choosing to ignore his advice and live my own life".
Over the years I've learned that my advice based on my up-to-date medical knowledge doesn't amount to a hill of beans. The best I can do is educate people so when they do make a decision it is made with understanding of both sides. This will _____, and that will _____ .
As I enter the world of 'senior citizenship' my need to control as much of my life as possible is paramount. Aging takes away a little bit of autonomy every day so let us live and die by our own decisions
Great piece!
Bad ending?
Do you mean he dies before his next trip to ER or that he has 4 more trips to ER before he dies? For my money & life, 4 more ER trips before dying would be thaw bad ending
Sign of a good life and likely many good decisions. Staying out of hospitals as much as feasible is also a good life skill to have. 97 and still able to make his own decisions, live as he wants, go for walks, talk to his niece everyday. Pray that every good person should be so fortunate.
Learned Helplessness
You accede to the patients wishes to be treated less aggressively. So did I before retiring. What other choice do you have, other than discharge them or commit them as insane? But what about the patient that wants unjustified testing or procedures? You don't accede to them readily, do you?
Well, you know people are free in the US to choose what they will.
I remember having a realization at some point, early on in being an attending, that I simply couldn't make my patients do anything. They had to want it. And not only was I incapable of forcing them, I wasn't sure I wanted to force them, anyway.
I still stand by radical bodily autonomy as a core principle of medicine. But it does open up big questions - what is the purpose of the doctor? What role can and should I play? And as patients get more access to information online - often the exact same information I have access to - I grapple with what role we doctors play, at all.
I think this patient's story already has a happy ending. First, being able to understand and articulate his preferences speaks to the quality of care he has received up to this point, as well as of being in an optimal psychological state. He is given the gift of autonomy, one that we all deserve as human beings. He alone knows what constitutes a "good ending" for himself, and he chose it. Bravo to you for not browbeating him. We should all be so fortunate to outlive the actuarial tables and have such choices in our waning days.
Heartily agree! Dr. Cifu, by stating your opinion and giving him space you have given him the best care possible.
"I expect this story will have a bad ending."
I doubt it! Dr. Cifu's patient has already made it to age 97 with independence, far more than almost all Americans, and putting him amongst the top 0.001 percentile on the planet. Only some trees, and many lies and racist beliefs have a longer average lifespan.
A bad ending is happening daily in Gaza, South Sudan, Ukraine, all over Africa and even to young people dying prematurely in North America. In Toronto, Canada, a sweet 8 y/o boy was killed by a stray bullet last week.
Meanwhile in rich countries, many people are lingering for years in states of complete dependence, no longer recognizable as the complete and often wonderful human beings they once were.
I take Dr. Cifu's posting as parable, with a taste of Jonathan Swift. And I'm looking forward to meeting him at the Preventing Overdiagnosis conference in Oxford a couple of weeks from now.
I found recently that reading Stefan Zweig: The World of Yesterday (published 1942) helped put many modern conundrums in context - including how easily and rapidly advanced civilizations lose freedom and collapse into barbarism. Many readers would recognize not only echos, but premonitions about where we are all being dragged in 2025.
Tom Perry MD (general internist, clinical pharmacologist)
It may pose an even harder challenge for those of us without children or young family to check in on us. Technology will help, we'll see when and if I make it to be old enough to need help.
The other angle I see is that of course seniors want to stay in the home they have always been in but they are too often a home that could house a whole family but is just housing the one person for years or decades. There should really be more options for downsizing without moving so far from the place you've lived.
As a car guy, you should give more love to The French Connection. In the GOAT discussion for best car chase scene ever. 😉
I’m always impressed by your caring and humanity. However, I do fall back on patient autonomy. If a patient is competent, and understands his choices…well, choices have consequences, and patients are entitled to them.
But I do acknowledge another level of discussion about societal/health care costs, which may have disparate implications in different healthcare systems.
I am with you, the car chase in FC is next level.