WHEN THE ICU CAN LEAVE YOU WORSE OFF.

Let’s start with the obvious:  the ICU saves lives that otherwise would end.  But the impact of this aggressive care can compromise life after release from the ICU.

This segment broadcast in June of 2016 describes the adverse impact of the ICU and speaks of a new diagnostic term Post-Traumatic Intensive Care Syndrome (PICS) describing the lasting emotional and cognitive effects of being in the ICU.

You will be able to see efforts by Vanderbilt University Hospital to help patients who are suffering with PICS.  It’s clear that  the ICU impacts emotional stability may also impair cognition.  But there is less research about whether the impact on cognition is a lasting or a transitory effect of the very heavy medication often used in the ICU.  Two very interesting elements to this video are (1) the statistic that 1/3 get better, 1/3 stay the same, and 1/3 get worse in terms of their psychological functioning and (2) that one of the patients (a physician) said he is absolutely terrified about  ever going back into the ICU.   Note that this patient was in the ICU longer than the three day average.

The ICU is mentioned in Chapter 4 of my book as an important issue to think about because of the implications for your overall welfare.

There is no doubt that the ICU saves lives through the use of high tech equipment, powerful drugs, and highly skilled physicians and nurses.  I know that I’ m repeating myself… yes, the ICU can truly save your life!  And this video says it can come with costs.  Show it to your family and proxy and think about what you want for yourself.  If you have an aging relative, show it to them and ask what they would choose: comfort care or aggressive care?

There are important implications for your advanced medical directives.  Serious conversations need to be initiated about how much treatment is right for you.  Keep in mind that age can play a substantial role in making the best choices.

 

Vegetative states and minimally conscious states and your civil rights

Finns, MD, Joseph “The Civil Rights We Don’t Think About.” New York Times, 8/24/17 Opinion page.  Published also on Sunday in the Review  Section (8/27/17 page 10.

Most advanced medical directives do not invite input into a variety of situations where a person may not be conscious.  The term “persistent vegetative state” which ordinarily suggests no brain activity is not even used in some forms.  This article suggests that it is even  more complicated and that there are marginal states where a person may be “minimally conscious” and able to express him/herself through a small action such as an eye blink.  There are even small indications that the brain can adapt and make repairs.

The article raises many questions about the treatment of these patients and the consideration of their rights to be consulted about their treatment despite limitations in their capacity to respond.

There are many comments responding to this article which may help you think through what choices you would make and whether you would want to anticipate and express your choices in your own directives prior to a medical event.  Consider doing the following.

Given the possibility that this could happen to you, what would you want for treatment?  Would you want to register your choices ahead of time in your directives?  How does your current age figure into your choices?  Are there financial concerns?  Are there concerns as to how your impairment would impact your family and those you love?  Share this article with your family.  Ask what they would want for themselves.  Then discuss your thoughts and choices.

Jessica Zitter, MD is featured in a compelling Oscar nominated documentary about difficult decisions.

Extremis, released in September 2016 is available to be streamed from Netflix.

This film is about the effort to make treatment decisions for patients who are gravely or terminally ill.  Dr. Zitter and others struggle to determine what a patient wants and then help the family make their best decision.  It is an elegant display of a caring physician and other health care providers attempting to do their best while knowing that providing more interventions can extend life but enhance suffering.

A review of this film in the Journal of the American Medical Association  (Jan 17, 2017 volume 317, number 3) states the following: “… many Americans will encounter end of life decision making – not as an active choice but, passively, with little or no opportunity to influence the decision or the outcome.” (pg 241).  This statement makes it clear that very sick patients can lose their voice in their health care.

Extremis is a stark and deeply moving testimony to the importance of deciding what you want and “having the conversation” with your family, doctor, and health care agent (Medical Proxy).  It illustrates the difficulty of making choices when there have not been adequate conversations and when there is an urgency to make decisions.

Dr. Zitter has also written a memoir Extreme Measures – Finding a Better Path to the End of Life which is to be published in February of 2017.  (Penguin)

Much of this film focuses on two patients who end up with different decisions with regard to breathing machines.  After viewing, try to decide what your choices would be if you were either of these patients.  Then show the film to your loved ones and proxy and have a conversation.  Begin by asking them what they would choose if they were one of these patients, followed by sharing your choices.

Take note of the ICU setting in which this drama plays out.  These units provide the most aggressive highest level of care that may: (1) save your life, (2) extend it without any improvement in the quality, (3) extend it and permanently decrease the quality of your life, or (4) possibly  result in your death.  What would you choose? 

 

 

YOUR LIFE, YOUR DEATH, YOUR CHOICE AN E-BOOK PUBLISHED EARLY OCTOBER 2016

YOUR LIFE, YOUR DEATH, YOUR CHOICE  How to Have Your Voice to the End of Your Life – is an e-book based on six years of research and teaching  providing you with the necessary resources for considering your end of life options.  It is…

  • WRITTEN FOR ADULTS OF ALL AGE
  • PROVIDES OPTIONS AND GUIDANCE  FOR CHOOSING YOUR MEDICAL PROXY AND ADVANCED MEDICAL  DIRECTIVES
  • ENCOURAGES REFLECTION , CHOICE MAKING AND CONVERSATION
  • GIVES DIRECT INFORMATION ABOUT THE  IMPLICATIONS OF YOUR CHOICES
  • USES MANY REAL EXAMPLES
  • ENABLES  INTERACTION WITH OVER 65 WEB SITES THROUGH LINKS TO VIDEOS,  POD CASTS AND ARTICLES             
  • SUGGESTS TOOLS AND STRATEGIES  TO “HAVE THE CONVERSATION” WITH FAMILY, DOCTOR, AND HEALTH CARE AGENT
  • ADDRESSES DEMENTIA AND MEDICAL DIRECTIVES
  • INCLUDES FORMS TO VIEW, DOWNLOAD AND PRINT

If you have an older adult who is not computer literate, buy it and read the book with her/him.  If you are younger, buy it for yourself.  As you will see when you read some of the examples, accidents and illness can strike at any time.

The book is available in a variety of formats for different kinds of tablets and computers.  CLICK HERE TO BUY THE BOOK .

NOTE: If  you choose to read it on a computer you must download ebook reader software.  I am using ‘Ice Cream” and it works well.  Type into your search engine “e-book readers” and select and download the one that appeals and matches your computer (Apple or PC).

And please offer your thoughts on this website about your reading, reflection, and conversations with those who are important to you.

Gray areas and the eventual cost of dementia care. It’s substantially more than for heart disease or cancer.

Gray areas…

In our “Having Your Voice” class, we talk about gray areas…the time when we begin to lose the ability to make effective decisions.

Anyone living long enough will experience this to some degree but, for some, it is the beginning of a more serious, substantial, and accelerated decline into dementia. It is important to appreciate that Alzheimer’s is not the only form of dementia… there are others that are equally devastating.

Gina Kolata’s article from the New York Times on October 26, 2015 states that the cost for treatment of heart disease and cancer for the last five years of life is roughly $175,000 while the cost for dementia care is $285,000.   The cost difference is due to the hands-on care required for caring for someone with dementia.

If you want to learn more about the impact on family, read “A Life Worth Ending”, a compelling article by Michael Wolff whose mother had dementia. He beautifully describes the woman she was, the last tragic years of her life, and the impact on the family.

What are the options for someone who develops dementia?
1. Having financial means helps because there are resources to support the person.
2. Having long term care insurance is valuable in gaining assistance.   However, it is expensive and usually has to be purchased when you are young and don’t need it. (Wolff comments darkly about the ongoing struggles to gain payment for services for which he asserts his mother is entitled).

While I am not advocating suicide, two well written articles address the decisions that were made by two women who were diagnosed with early onset Alzheimer’s disease. Both women recognized the loss of dignity and the many burdens they would place on others as their disease progressed. They made a different choice.

Gilean Bennet, a former professor and psychotherapist who lived in western Canada, wrote a farewell that described her reasoning and decision to take medicine to end her life. It includes comments about the needless expenditure of resources when there was little that would bring her a satisfying quality of life.

Robin Henig wrote about a professor of psychology who carefully researched how to take her life after she was diagnosed with early onset Alzheimer’s disease.  Although she didn’t want to take her life, she knew that she would get to the place where she couldn’t because of the impairment of her disease. Henig describes how her impairment almost defeated her intention.

In the realm of Hollywood films, “Still Alice” beautifully depicts the dilemma faced by a professor diagnosed with early onset dementia. It depicts Alice’s failing in an attempt to take her life because she was too impaired to complete the act of taking pills. Clearly, in patients with dementia, the window of opportunity to take their own life closes at some point.

QUESTIONS FOR YOU
As always, there are profound and difficult questions for you to ponder. Here is a brief sample:
1. What would you do if you were diagnosed with a progressive incurable form of dementia?
2. How much medical care would you want to sustain your life (such as for blood pressure, cholesterol, heart medication)?
3. Are there family members you could identify who would be willing to care for you?
4. Do you or they have the resources (financial, personal, spiritual, etc.) to care for you?
5. Would you consider taking your life if you were able to do it?

Share your responses to these questions with your family. It’s an important conversation to have.

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