Healthy Journalism

Monday, February 6, 2012

Breaking my long silence

Blogging is supposed to be personal.

But it’s been impossible for me to write anything personal about health or medicine since Irwin died nine weeks ago, on November 28. Every time I’ve tried, the noise in my brain has silenced my fingers.
My mental attic is like the Collyer brothers’ infamous apartment: stuffed with facts, factoids, memories and opinions about the risks and benefits of modern medicine, the perils of over-treating elderly people with multiple diagnoses, and the outrageous costs involved.

Now I’m pushing through the teetering stacks and digging out a few observations to share.

First of all, thank God for geriatricians who don’t feel compelled to practice heroic medicine.

Irwin was an old military man who smoked during his 27 years in the Army and probably drank more than his share, too. But by the time he and my mother married in their 70s, he was a physically active guy, not overweight, who no longer smoked and who enjoyed one beer a day. Within a couple of years he developed a pleasant form of dementia, his chronic obstructive pulmonary disease worsened, and he had several small strokes.

Pretty soon it became unsafe for either of them to drive in rural Florida, where nothing was in walking distance, and they moved next door to us in 2008.

Irwin was 81½ years old when he and my mother became patients of an Athens internist who is board certified in geriatrics. To her credit, she weaned him from some of the many drugs he’d been prescribed in Florida, where he drove from specialist to specialist but had no one coordinating his care.

Irwin was not the easiest patient to deal with. He’d been a medic for 25 years, and didn’t realize that dementia had stolen much of what he’d known. So he held a lot of opinions. Also he read dozens of popular health magazines and newsletters, some reputable and some not so, and he wanted every test and surgery he read about. The doctor reassured, rarely referred, and calmed Irwin’s worries. They had a good relationship.

The doctor was genuinely worried when she saw him on Halloween. The presenting complaints were fatigue, worsening confusion, a swollen belly and episodes of urinary incontinence. She ordered a battery of blood tests and by Friday we knew that he had liver failure. At her suggestion, we updated his advance medical directive.

Irwin’s condition tanked over the next two weeks. He was admitted to the intensive care unit at our nearest hospital on Nov. 15. X-ray, CAT-scan and ultrasound studies indicated he had lung cancer that had metastasized to his liver and that both were advanced. We knew he would not come home again.
Seven days in the hospital cost $37,612.

That’s a great deal of money but the tab could have been worse. Although the imaging studies clearly indicated cancer, we could have given the go-ahead when an oncologist said he could confirm the diagnosis by biopsying lung and liver, and that chemotherapy might be an option.
Our family decided to pass, and Irwin’s primary care doctor agreed.

There was no point in keeping Irwin hospitalized after we turned down additional procedures and treatments, so the discharge planner helped us arrange transfer to a local nursing home where hospice care was available.

After one week in the nursing home, Irwin died peacefully with us at his side. He was 84½ years old to the day. His final illness was short, no one was pounding on his chest or intubating him when he died, and our family was not bankrupted by the experience.

One reason Irwin’s last illness was brief is that his geriatrician discouraged him from mobile “whole body cancer scans” and other dubious diagnostic road shows. What would have happened if we’d learned he had lung cancer one or two years earlier? Irwin and my mother might have insisted on biopsies, surgery, chemotherapy – harsh, expensive interventions that can worsen the quality of life without extending it by a day.

As it was, we lived with the knowledge of his terminal cancer for only two weeks – which was long enough.

I’m grateful for the advance medical directive that kept the crash cart out of his room and allowed a quiet death.

Finally, we’re all thankful for Medicare Parts A & B and for Tricare for Life, the health insurance benefit earned by career military personnel.

None of which changes the fact that we miss the old guy every day. You can read his obituary here.