published Thursday, August 27th, 2009

Cleaveland: Problems in senior citizen health care

Medical technology is so sophisticated that the lives of elderly Americans theoretically can be extended indefinitely. Mechanical ventilation, cardiac assist devices, feeding tubes or intravenous nutrition, dialysis for kidney failure -- these tools can tide us through a severe illness or give us a chance to recover from major surgery or injury.

But how and where should we draw the line in the use of these marvels? These are limited resources, and their deployment is very expensive. If there is no prospect for recovery, these tools could keep us around for years in an unresponsive state in an intensive care unit, emotionally and financially exhausting our families. I have quoted Duke ethicist Harmon Smith earlier: "Who gets how much of what when there is not enough to go around?"

Years ago, Kurt Vonnegut captured the dilemma posed by such interventions in a short story. A rich, elderly lady existed as a head atop a tripod. A team of scientists labored constantly in the basement of her home to provide the nutrition and oxygen that flowed through the legs of the tripod to sustain her. She lived for the weekly visits of her hair stylist.

An obituary in the New York Times of August 24th illustrates one approach to this complex issue. A 101 year old Harvard cardiologist, A. Stone Freedberg assessed his failing health. "It is time to draw the curtain," he stated to a close friend. "He then refused food and water, invited family and friends to say goodbye and died in his sleep." The elderly physician was fortunate. He had an intact intellect and full information on the treatment options at hand.

Living wills and health care directives allow each of us to establish our preferences while we enjoy the gifts of reason and reflection. This is the legal framework by which we declare how we wish treatment to proceed if we are in a sustained coma or demented or otherwise in a state in which our reason is impaired and unlikely to recover. We can appoint a relative or friend to carry out our preferences should we become incompetent to make decisions.

Unfortunately, most seniors have not completed these documents. Such discussions need to be carried out within the framework of our closest family or most trusted friends. Our religious counselors and attorneys can assist these deliberations.

But what if a senior or his family demand every possible therapy when there is no prospect for recovery? I have known of elderly people who have given large sums of money to medical centers to gain a place at the top of organ transplant lists.

I have been in the middle of complex debates among family members wherein one faction want comfort care for a very sick senior and the other want "everything possible done." There are no clearly established guidelines for such complex circumstances.

Perhaps the saddest spin-off of the current debate over health care has been the specter of "death panels" -- of committees that would arbitrarily establish who lives and who dies when severe, chronic illness afflicts a person. No piece of health reform legislation currently under consideration by Congress even mentions such panels. This is a scare tactic by some opponents of change in our health system.

As a civil society, we must consider Harmon Smith's question. In our houses of worship, our schools and colleges, our civic groups, and our health care institutions we must begin consideration of the nature and quality of life at its far end.

Is life simply a heartbeat recorded on a monitor? Is life present when sensitive brain-wave recordings indicate a sustained absence of higher brain function? Should every senior die in an ICU surrounded by machines? Should personal wealth or social connections determine how life-support technology is allocated? What is fair? What is reasonable?

Scare tactics and heated, political rhetoric will solve nothing. We must reason together.

E-mail Clif Cleaveland at Cleveland1000@comcast.net.

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