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PUMPING IRONY: Decisions, Decisions

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When critical illness strikes, elderly patients often have less control over their treatment options than they would prefer. Recent research — and my own experience — suggests that better communication could create better outcomes.

A few weeks after my mother celebrated her 80th birthday, she visited her doctor for her annual check-up and returned home with some troubling news: A tumor had sprouted behind her ovaries. The “C” word quickly spread among family and friends, triggering a flurry of discussions dominated by siblings who refused to consider anything less than heroic measures to keep her around as long as possible. Surgery and chemotherapy ensued, draining the life out of her; she aged 10 years in a few months. Two years later she was dead.

I chose to remain on the periphery of that drama, knowing that my unconventional views on end-of-life care would do little to comfort those who most needed to be comforted, but I remain convinced all these years later that Mom’s final months would’ve been less fraught had she managed to avoid such draconian treatments. Recent research, however, helps to explain why that didn’t happen in her case — and why it’s such a common closing episode in so many other lives.

When British analysts reviewed the results of 57 major studies in an effort to determine how the elderly tend to respond to a critical illness, they found that the concerns of family members influenced their choices more than any other factor. “Often, older adults changed their preferences based on the concerns of family members or a wish to avoid ‘being a burden’ to others,” lead study author Simon Noah Etkind, MB, BChir, explains in the Journal of the American Geriatrics Society.

My mother was no martyr, and she had lived independently since Dad’s death 23 years earlier, so there was little concern about her burdening any of her offspring. But she was compassionate to a fault and couldn’t bear to see the suffering of those around her who couldn’t bear to see her go without putting up a fight.

She was also a normal American healthcare consumer, someone who followed the rules of the game. You go in for an annual pap smear when you’re 80 years old because that’s what the doctor tells you to do. How else would you discover a tumor, after all? But was it fast-growing, slow-growing, receding? Would it cause her death or simply accompany her to the grave? I can’t be sure that she asked those questions, but I don’t doubt that she never questioned the answers.

And once in the treatment vortex, the elderly often find themselves at an immediate disadvantage, because doctors are much less likely to opt for minimally invasive surgeries (MIS). A recent Johns Hopkins University study reviewed more than 200,000 Medicare cases in which patients underwent seven common procedures and found barely half of them experienced less-invasive treatments — a lower percentage than in the general population.

Lead study author Caleb Fan, MD, and his team reported that complication and readmission rates among those patients who underwent invasive surgeries were higher than among those treated with MIS.

“Despite strong evidence demonstrating the clinical and economic benefits of minimally invasive surgery, utilization of MIS in the Medicare population is highly variable and tends to be lower than in the general population,” Fan notes. “MIS benefited Medicare patients undergoing a range of surgical procedures. MIS was associated with fewer complications and readmissions as well as shorter length of stays and lower Medicare costs and reimbursements versus open surgery. MIS may represent a better quality and cost proposition in the Medicare population.”

It’s tempting to assume that the trend toward more invasive treatments is a product of panicked seniors pleading with their doctors for the kind of heroic measures that sent my mother into her two-year decline, but the latest research tells a different story. A University of Michigan survey found that only 14 percent of people over 50 believe more is better when it comes to treatment options. About one in four reported that their doctor ordered tests or prescribed drugs they didn’t think were necessary. Despite those concerns, nearly half of them agreed to the tests and took the pills, a phenomenon lead study author Jeffrey Kullgren, MD, MS, MPH, says reflects an inability for patients and physicians to effectively communicate.

“Patients should speak up when they aren’t sure if a test or medication recommended to them is needed,” Kullgren suggests. “And providers need to communicate about how a particular service will — or will not — affect the patient’s health, both when they’re recommending it and when a patient has requested it.”

I have my doubts that any level of discussion would’ve swayed Mom’s decision to go ahead with surgery and the rest after her diagnosis; she was thinking more about her offspring’s comfort than her own. Her decision and its aftermath, however, did have a profound effect on some of those she left behind. I’ll never forget my mother-in-law’s response when she heard about Mom’s final months. “I don’t want to end up like Ruth,” she said.

Years later, when a stroke laid her low at 85, she refused any major interventions and navigated her final months with a dignity and ease that inspired all those around her. At the end, there were no decisions to debate — just a slow, peaceful journey to a welcome destination.

is an Experience Life deputy editor who explores the joys and challenges of aging well.

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