How Many Years Do I Have Left to Live? (Table)

I had the gracious opportunity to perform cardiopulmonary resuscitation on a 93 year old.  93 years old.  Let me say that again.  93 years old.  Full code.  93 years old.  The concept blows my mind.  Why?  Why?  Why?  What are the odds of dying for a 93 year old? 

I find these actuarial life expectancy tables highly interesting.  It tells you, on average, at each age, what your expected life expectancy you have left is.  I don't know all the mumbo jumbo statistics that go into these figures. I guess I just accept them at face value.  Lets take a peek...

As of July 9th, 2007,
If you are 65 years old, you can expect to live 19.20 more years.
If you are 75 years old, you can expect to live 12.04 more years.
Turn 85 this year? You can expect to live 6.43 more years.
How about 95. That's old. But you still got, on average, 3.09 years left in you.
If you are 105 this year, better make out your will. You only have 1.63 years left in ya.
If you are 119 years old this year, you better go on that Caribbean vacation you've always wanted. You only have 0.53 years left in ya.
Now, statistics lie. Or at least can be bent pretty easily. My patient that coded? She had renal failure (I guess who doesn't at this age, right?)  So does anyone really believe she has 3.83 years left in her? For all comers at 93, there is a 20% chance of dying in one year. Hardly. I suppose that 3.83 years includes all comers. You see, some will die in 1 month, some will live to be 105.  Her probable mortality at 30 days approaches 100%.

That is a reality.  If you are 93 years old. And you have renal failure.  And you code.  You should allow yourself to go gently into that night.  Trust me when I say that. Your life, your quality, your independent functioning life as you know it? It's over.

Instead, patient and family  chose an ungrateful march toward mortality  So where are we know?

ICU
Central line
Ventilator
Tube feeds
Drips
Drops
Pulling out all the stops.

and on and on and on. Why? Why all this madness? One reason. Fear of mortality. The inability to accept mortality.  Why not do all this? Well, I can think of hundreds of reasons why not. But lets just say that this $50,000 + escapade (in the spirit of unmanaged upset patients). To cheat mortality for another few weeks could have provided a well baby check for over 250 babies.  It could have provided groceries for a month for 100 families  It could have provided heating assistance for 250 families for one month.  It could provide 4 years of college at a state institution for one highschool graduate  You see, when we cheat mortality out of its peaceful end game, we create death and disability, morbidity and mortality for an exponentially larger population. The moral good loses.

250 kids
100 families to feed
250 families to heat.

Is it ethical to sacrifice the many for the few? Should we place extreme hardship on the many to delay the already defined outcomes of the few?  I say it's not. My ability to spend millions of dollars to deny the peaceful end of a wonderful life existence, through the fully funded policy of coding 93 year olds, only to create that ungraceful march at the expense of 1000's of suffering people without the resources to survive.


That is of course, unless you believe in fantasy land economics. That we can have it all.  All the time.  Where along the way, did we as a society decide that cheating the inevitable grip of death in a natural quick and painless way was morally superior to providing enough resources to help poor people eat, get heat, get educated and allowing the future of our population waddle in inadequate care.  I can think of no other better way to die than to code. Immediate death.  Do I place less value on the 93 year olds life than a child? No. Never. Everyones life is equally important.  Do I think as a society, in a land of finite resources, that having society pay to code a 93 year old instead providing well baby checks for 250 children is appropriate? No.  FREE=MORE, until all the money is gone. Then MORE=LESS

I don't know anyone who believes that all care can be provided all the time at government expense.  You simply stop breathing and pass out. It is the most peace, comfortable and painless way to die. It is the choice that I would pick 100 out of 100 times.  There is no suffering.  Yet here we are. Creating suffering for the patient. Creating suffering for all the lost opportunity cost of helping others.  It's LOSE=LOSE  And before anyone chimes in that I'm playing God with these decisions, remember doing nothing is a God like natural end. Doing everything is not

Years left to live actuarial chart photo


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16 Outbursts:

  1. So don't do it.

    Just. Say. No.

    You took a gig in hospital internal medicine. You *KNEW* the payor mix was gonna be largely Medicare, the "insurer of burning houses". You had to have seen plenty examples of this phenomenon in your education, probably well before residency. The studies about end-of-life care costs and how 5% of the population eats up 55% of the money for healthcare aren't new. We've known for years that people with terminal diagnoses frequently die in the ICU. Hell, I know these things and I'm no more a physician than a physicist.

    So. Don't participate. Pull a Ron Paul.

    Don't take the money from 'em. Don't take a gig where coding 93 yos with end-stage disease is de rigeur. Don't practice in an environment where you have to accept every patient that comes to you.

    You're inflicting suffering on little old ladies in the middle of the night. It's probably a good thing that you're obviously conflicted about it (it's clearly not just the money). You're miserable being funded by the Medicare National Bank, Home Of The I Want It All And I Want It NOW Account.

    Were I in your position, I'd be suffering from a raging case of terminal cognitive dissonance. It's not an enviable spot.

    E

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  2. eric.

    I think there is a utter lack of education out there about managed expectations.

    I love my job. I just wish patients and families understood that what they ask us docs to do to their 93 year old mothers and grandmothers is so much worse in terms of pain and suffering than letting them go peacefully.

    That's all I'm saying.

    Payer source has nothing to do with me coding a 93 year old.

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  3. The fact that the rest of us have to pay so much money to provide futile care for those unwilling to come to terms with their own mortality is sickening.

    Why is this kind of case more than an anomoly? What are we doing wrong as a society?

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  4. Claiming payor has nothing to do with the care delivered is disingenuous. If nobody was getting paid for it, we wouldn't do it (or at least not as often). I suspect (and should probably dig up actual citations) that at least 75% of the futile "care" delivered in the US is paid by public funding.

    Maybe full-coding 93-yo ESRD patients should be a "Never Event". Turn off the flow from Medicare National Bank, it'll stop. Families will have to decide if losing an inheritance, the family house or mom's jewelry is more important than three weeks in a hospital.

    Until there's a consequence for unrealistic expectations, there's not going to be behavioral change.

    E

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  5. erik, If I made a unilateral decision not to code a patient in spite of their legal directive to do so, I would get my ass sued quicker than a Texas two step.

    If medicare pulled the plug on funding for CPR in a 93 year old, and a patient/family still wanted it done, I would do it, because not doing to would get me sued.

    So, like I said before, payer source has nothing to do with it from my stand point.

    No, the patient/family may think twice about it if their money was on the line.

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  6. Do you think that some of this is due to being cared for by a hospitalist rather than a physician who has known the patient and family for years? I'm not anti-hospitalist by any means. You guys do a great job, and community primary care physicians have almost completely given up hospital care because of the payment system. Nevertheless, I think this is a situation where the lack of a long term trusting relationship with the attending physician leads to a reluctance to make the DNR decision.

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  7. What about a really good walkie-talkie nondemented, independent 93 year old? (no renal failure) I think it might be worth a try. Of course if the code is not successful quickly - ie the patient is likely brain dead - then you obviously put on the breaks. I had one non-demented 90 something year old come in with vtach - we coded him successfully and he left the hospital in a about a week with an AICD. Of course I COMPLETELY agree about the stroked out bedridden gomes.

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  8. Happy, I think you wrote a compelling tale and these families want codes because they are IGNORANT. They have watched too much TV and they think Gramma will walk out well. They have not been told about renal failure and the lousy prognosis of recovering from a code. They are in denial about aging and death. We are a society that fears death and doesn't realize that a quick death at 93 is a blessing.
    Of course you are in a bind and are forced to go through the "heroic" motions. Unfortunately, once the patient is in ICU on drips and support, it will be a long, slow (ridiculously expensive) decline.

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  9. I have to wonder the understanding that the family has of this. There are times when a physician doesn't want to honestly lay out the unpleasant truth of the situation, and the family makes choices based on faulty information.

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  10. For those who have no idea how it works, you can't explain the concept of DNR to a family when the code blue alert has already been called. Seconds count. Unless a DNR is on the chart, you must respond with full ACLS support. Anything less would be lawsuit city.

    In this situation the family was right there as all this was going on. They knew exactly what was going on. They had every opportunity to say stop.

    When our team saved 93 year old mama and sent her to the ICU. I talked to the daughter. I explained this this would likely happen again tonight and what would you like us to do if it happened again.

    The response?

    Do what you can.

    TK, like most things in life there are exceptions to every rule. The vast majority of 90+ year olds who code will never make it home, let aloe a nursing home.

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  11. I think people in general are ill informed about the efficacy of codes.

    They see on the medical dramas that someone pulls out the paddles, shocks asystole and the patient recovers.

    They don't realize that in few cases does coding a person work. And that in even fewer cases does a person who recovered from a code survive to leave the hospital.

    We code patients because sometimes it does work. But the chances are very small. And the more co-morbities, the less of a chance of success. The public needs to be educated that this is last-ditch and in most cases not worth the pain and trauma inflicted.

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  12. I'm not a medical doctor, but this is something I've been giving a lot of thought to. I'm trying to figure out when I should issue a DNR order on myself. I'm 54 and in good health, but there is no way, at the end of quality life, I want to be even put on the machines.

    But is that an appropriate position to take now?

    Does anyone have any guidelines on when I should look into that "DNR" tatoo on my chest (in case the papers get misplaced)?

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  13. Theresa - you are definitely not a candidate in my book for a DNR. You are the perfect candidate for a living will. Make your wishes known to your family members. Let them know that if for some reason you collapse at home and need emergency care, that yes you want that! You have a good quality of life and want to maintain that.

    If your quality of life was in the toilet, if you didn't have the ability to think for yourself, if you couldn't feed yourself or take enjoyment in your daily life --- a DNR would be a serious consideration.

    A living will spells out what kinds of interventions (feeding tubes, IV antibiotics, etc..) you want to sustain your life. They are a great tool.

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  14. Awww... the 93 year old code. I see it so often in the ER. Some of you speak of money, some of you say "just don't do it" and some of you say what a waste of resources. I guess since everyone has an opinion, I'll give you mine as well.

    In my opinion, there are a number of things that contribute to the coding of a 93 year old chronically ill person (who has probably been living in a long term facility for a number of year), the least of which is money and a waste of resources. What I've seen in the ER is that families have issues not with death and dying, but with quilt. That's right I said it out loud, GUILT.

    Generally the chronically ill 93 year old dad or grandpa has been living in the nursing home for years, most of the family haven't seen him for months except perhaps on a holiday. When the "end" approaches, the family feels better by being able to say, "We did everything but they just couldn't save him."

    My mother was 72 years old when she died. She had end stage CHF and her wish was to go home to be with her family. She did not want to live on a ventilator with pressors and routine chest compressions to save her life.

    What did I get to tell people when she died? I got to proudly say, "My mother died at home, surrounded by her family in comfort and dignity. I'm proud that I was able to do that.....and I feel absolutely no remorse in giving her the quality of death that she had in life.

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  15. Teresa:

    An advanced directive is probably what you need. A Living Will is one form of that, a Power of Attorney for Healthcare is another thing you can do, by designating a representative, in advance, to make decisions when you can't.

    Better than a living will, though is the POLST, Physicians Orders for Life-Sustaining Treatment. Unlike a Living Will, which can be ignored in certain circumstances (especially by prehospital responders), POLST carries the weight of an MD's orders. Check out http://www.polst.org , a service of Oregon Health And Sciences University, which has information on POLST Paradigm around the country.

    E

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  16. 'Full code' is a default status to the added conditions on limitations for resuscitative efforts.

    You are not obligated to provide all of the interventions rattled off on your list:
    "CU
    Central line
    Ventilator
    Tube feeds
    Drips
    Drops
    Pulling out all the stops."

    You are obligated to use judgement and discression as a physician. Provide those elements of care that have some reasonable probability of providing either quality or quantity to life. You cannot do these things as a mindless automaton, then complain that it was you who initiated inapropriate care. If you want to be a physicain, then be one; if you want to be a technician in ICU care then shut up and follow the protocol.

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