Medicine For People!

May 2012

Elderly Person

Drug-Addicted Grandma?

Recently a patient consulted me about her 93 year old mother, crippled with painful arthritis. No ordinary pain medication allowed her mother to move comfortably. She had begged her mother's doctor to prescribe Vicodin or similar to give her mother some relief, but the doctor refused saying that he did he did not want to get her mother addicted to pain medication. I shook my head in disbelief. Younger people are poorly served by unnecessary opiates. But this woman was looking at unremitting agony for the few years remaining in her life. Wasn't she better served by using medication needed to help her feel better? Certainly we'd have to adjust the dose to her age, but mercy dictated that we govern our action by her stage of life.

Time is of the Essence

Of all the mistakes we doctors make, denying comfort medication to the elderly is one of the saddest. When will we learn that we can't go on auto-pilot prescribing medicine? As we've argued in many newsletters, there's a time to push, to go beyond the textbook for a cure. There's also a time to stop pushing, to care and comfort, as you can read here. When we take time into account in our medical decisions, we don't impose unnecessary suffering on people.

This newsletter is about time and how it changes our medical needs. When we ignore time, we fail to treat people with compassion and dignity.

Let's Get Realistic – People Don't Live Forever

When you are 15, you are looking at uncountable years ahead. When you are 65, you are looking at 20 years. When you are 95, the number shrinks to a little over three. These Life Table Charts[1] tell the story.

Table 2. Life table for Males: United States, 2007


Of 100,000 men born, how many survive to this age

Of 100,000 men born, how many die this year

Expectation of years remaining

65-66

79,726

1337

17.2

66-67

78,388

1,432

16.5

67-68

76,965

1,515

15.8

68-69

75,450

1,609

15.1

69-70

73,841

1,709

14.4

70-71

72,132

1,818

13.7

71-72

70,314

1,942

13.1

72-73

68,373

2,080

12.4

73-74

66,293

2,227

11.8

74-75

64,066

2,308

11.2

75-76

61,685

2,535

10.6

76-77

59,150

2,680

10.0

77-78

56,470

2,820

9.5

78-79

53,649

2,592

8.9

79-80

50,698

3,071

8.4

80-81

47,627

3,175

7.9

81-82

44,452

3,258

7.5

82-83

41,194

3,318

7.0

83-84

37,876

3,350

6.6

84-85

34,527

3,350

6.2

85-86

31,177

3,315

5.8

86-87

27,861

3,244

5.4

87-88

24,617

3,135

5.1

88-89

21,482

2,989

4.8

89-90

18,492

2,808

4.4

90-91

15,684

2,595

4.1

91-92

13,089

2,357

3.9

92-93

10,732

2,100

3.6

93-94

8,632

1,832

3.4

94-95

6,801

1,563

3.1

95-96

5,238

1,301

2.9

96-97

3,937

1,055

2.7

97-98

2,882

831

2.5

98-99

2,051

635

2.4

99-100

1,416

470

2.2

Table 3. Life table for females: United States, 2007


Of 100,000 women born, how many survive to this age

Of 100,000 women born, how many die this year

Expectation of years remaining

65-66

87,494

941

19.9

66-67

86,553

1,012

19.1

67-68

85,541

1,088

18.3

68-69

84,453

1,168

17.5

69-70

83,285

1,254

16.8

70-71

82,030

1,352

16.0

71-72

80,678

1,466

15.3

72-73

79,212

1,596

14.5

73-74

77,616

1,742

13.8

74-75

75,874

1,901

13.1

75-76

73,973

2,072

12.5

76-77

71,900

2,244

11.8

77-78

69,656

2,422

11.2

78-79

67,234

2,602

10.5

79-80

64,632

2,784

10.0

80-81

61,848

2,963

9.4

81-82

58,885

3,136

8.8

82-83

55,749

3,298

8.3

83-84

52,451

3,445

7.8

84-85

49,006

3,570

7.3

85-86

45,436

3,669

6.8

86-87

41,767

3,735

6.4

87-88

38,032

3,762

6.0

88-89

34,270

3,746

5.6

89-90

30,525

3,682

5.2

90-91

26,842

3,569

4.8

91-92

23,274

3,406

4.5

92-93

19,868

3,195

4.2

93-94

16,673

2,942

3.9

94-95

13,731

2,653

3.6

95-96

11,078

2,339

3.3

96-97

8,739

2,013

3.1

97-98

6,726

1,686

2.9

98-99

5,040

1,372

2.7

99-100

3,668

1,081

2.5

You can complete a questionnaire at http://gosset.wharton.upenn.edu/mortality/perl/CalcForm.html for a more customized estimate.

Once we acknowledge that we will die, the question is no longer how to live forever but how to live for now.

Acting as an Advocate for your loved one

Time alters everything. Once upon a time she was your mother and took care of your every need. Now may be the time she needs your help.

Accompany Your Elder to Doctor Visits

As the end of life approaches, your relationship with your loved one will change. Your parent may want to talk to you more about their health. That's a good time to make a visit to their doctor with him or her, for two reasons. First, there may be a note in a chart that you are the next of kin, but that becomes more a reality in the mind of the physician and his assistants once they have met you. Now they are much more likely to remember and consult you. Second, your parent will notice that you are taking an interest in their medical care. When you start soon enough, there will be nothing to do during this first visit except introduce yourself and be there for your loved one. Later, if the medical team needs you to explain things or convince your loved one that this or that course of action is best, your loved one will see this as a natural progression and not as an intrusion.

Pay Attention to Your Elder's Meds

As advocate, you will be noticing how your parent reacts to medication. If you think Dad needs a higher or lower dose of medication or you are concerned about other quality-of-life issues, you will need to speak up. It's up to you to make sure your parent's needs are heard.

Talk About Elder's Wishes

You might notice that when your doctor needs to talk to your loved one about an end-of-life issue, they'll often ask permission. You can do the same. Ask permission and go by the answer. Let Dad or Mom tell you about their own comfort with the topic of death before you go charging in. Instead of "Mom, we need this form filled out so we can pull the plug and stop CPR without cutting too much into my afternoon," you can say "Mom, do you want to talk to me about what I should do if you are seriously ill and cannot make your wishes known?" Write down what they say! Later you'll be thankful you did.

Talk About Your Feelings

If you may be called upon to act as advocate for a loved one, you might also want to tell that person how you feel about making life and death decisions. These are not simply mechanical or legal issues. There are going to be major feelings and your loved one will know that and may wish to talk about it or hear about it. Also, you need to be sure all your siblings are on board. If not, buy an extra-large bottle of aspirin. You're going to need it.

Do the Paper Work

Most of the people we see at our office already have a will, an advance directive, a power of attorney for health matters, and when the time comes, a POLST form [Physician Orders for Life-Sustaining Treatment www.polst.org. This is a green form every medic team will look for when it arrives in a home with someone in extremis. This short and simple summary of an advance directive tells what the individual wishes done and does not wish done should life begin to ebb.

Respect

As you take more responsibility for your loved one, you can be their advocate with his or her doctor.

Ideally, your parent's doctor will address herself to them when they are in the room. Even if your parent loses some mental function, they can tell when they are being treated with respect. Not all doctors develop skills in end-of-life care. You may wish to gently steer your loved one into the care of one who does.

Living While Dying

There is no way you or I can help your mother or father prepare for death. In fact, almost all the time I find that people have already done this on their own, and admirably too. I think it is built into us. We live our lives in the midst of the inevitable disappearance of our elders and peers. Those absences make a growing impression as time goes by. In fact, your parent, in this process, will likely be teaching you.

You have a great privilege if you are with them at this time, and they give you their last gift.

Endnotes

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington. Edited by Carolyn Latteier.