|Summer Calm—image by the author|
“Doctor, I want you to treat her as a forty-year old!”
What is the appropriate answer to a demand like that from a daughter about the treatment of her eighty-eight-year-old mother? Any suggestion that her mother might not do well even with the best treatment in the world is anathema to her. She keeps mentioning how her mother has always recovered from severe surgical stresses. I ask her when that was: she reckons that her last hip replacement operation was twelve years ago. She seems unable, or unwilling, to grasp the fact that this is a very long period of time, and that so many things can change even from day to day, especially in an elderly person.
The mother now has advanced dementia, which was not a problem in those distant days. In the course of her current hospitalization she has already had a pacemaker inserted (on borderline indications), an associated hydropneumothorax which required prolonged intercostal drainage, she is fed by nasogastric tube because of aspiration pneumonia, and requires noninvasive ventilation periodically during the day. On top of that, she does not communicate at all, and cannot obey commands or cooperate with respiratory physiotherapy or mobilization. None of these facts seem to matter to the daughter who wants the very best and is adamant that her mother is going to pull through.
Admirable though her optimism may be, there are biological limits to what even the best possible care may achieve. However, my arguments to this effect are in vain. So I simply say that I can treat her as if she were forty, but she is unlikely to respond any better than a demented eighty-eight-year-old (this is a realistic and not a derogatory description). I feel sorry for her—the daughter, not the mother. Her mother may pull through this episode, but there will be another. If she does not make it, the shock to the daughter will be severe, and she is likely to need specialist counseling.
My attempts to prepare her for the worst potential outcome are interpreted as neglect for the patient. I am not a proponent of euthanasia in any form, but there are times when I feel that the time-honored concept of letting nature take its course was an option founded on common wisdom rather than on lack of scientific knowledge or technical resources. Ignoring it in patients with severe, complex, and advanced disease may lead to inappropriate interventions and overtreatment, and may indeed constitute bad medicine.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He graduated from the Aristotle University of Thessaloniki Medical School. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, and specialized in Pulmonary Medicine. He also holds a postgraduate Diploma in Palliative Medicine from the University of Cardiff, Wales, United Kingdom. He is a postgraduate instructor in palliative medicine at the University of Thessaly, Larissa, Greece. He also edits the journal of the Thessaloniki Medical Association, and blogs regularly.