Facing the end of life...

Dr. Wayland Marks is the Medical Director for

 Medi Home Hospice Fredericksburg

This op-ed column for Viewpoints on end-of-life issues: Meeting the medical needs of frail, older people

 was published in the Fredericksburg Free Lance Star on 4/3/2011

This blog contains excerpts. The link to the full article will be posted at the end.

THERE IS a group of older individuals who have little or no formal recognition or representation. They do not sit in on focus groups, write letters to the editor or to their congressman, and usually do not vote. These are the frail elderly, usually over 80 years of age and many 90 and older.


In 1900, longevity was less than 50 years; when Social Security was instituted in 1934 death usually occurred by age 65. Now it is common for individuals in their 50s and 60s to be caretakers for their parents in their 80s or 90s. Society has never had such demographics. When the older patient becomes acutely ill, he is handled the way a much younger patient would be: sent to the emergency room, scanned, tested, admitted, and treated. Unfortunately, with incurable diseases, this scenario is often repeated many times prior to death.


If the older, frail patient survives the hospitalization, he is often weaker than before hospitalization and many require a nursing home transfer instead of returning home. Unfortunately, the nursing home is where many will die. Forty-two percent of individuals over 85 will die in a nursing home, 34 percent will die in a hospital, and only 18 percent will die at home, where virtually all would prefer to be.


Typically during these months, major decisions concerning medical care, financial matters, and residence are made, not by the patient, but by the adult son or daughter who understandably believes that more medical care must be better.


Dr. Marks poses a probing question:

• Why do so many of these individuals receive care that may be harmful to them and care they would probably refuse if they were able to understand and participate in the decision process?

Lack of planning: 

We encourage people to prepare wills, undertake estate planning, consider life insurance and long-term care insurance, but when we advise planning for the possibility of severe disability near the end of life, we employ the term "death panels" and the discussion is usually neglected. Adult children often end up making decisions for their disabled parents without specific guidelines, usually opting for more medical care, sometimes to include tube feedings and intubation with mechanical ventilation of severely disabled older patients.

Misallocation of resources:

Medical care is reimbursed for utilization of medical services. When a patient is hospitalized, the system typically pays more for more consultations, more CT scans, more procedures, and more treatments. Our reimbursement system is similar to our asking the electrician to decide where to place all electrical outlets in a new house, and reimbursing him for each outlet. Medicare will pay for surgery for a seriously ill 90-year-old woman who may well die in a few months, but will allocate no resources to help a 90-year-old woman remain functional at home and avoid nursing-home care.

Unwarranted expectations:

Of the many chronic illnesses outlined above there are virtually none that are curable and, of course, the certainty of death is 100 percent. Most older patients are able to understand and appreciate the certainty of death, which is neither unnatural nor unexpected after an active 80 or 90 years of living. Replacing a desire for longer and longer life, there is more often an appreciation for quality of life, a focus on comfort and relief of pain and shortness of breath, and a desire to be at home with a loving family if at all possible.

There clearly needs to be an understanding that this unique group of individuals is different. For 80 or more years they have focused on the quality of their lives and, when approaching life's conclusion, most of them prefer the same focus. We must shift health care resources to meet their needs with less hospital care, fewer scans, tests, and procedures, and to put an emphasis on providing meaningful care in the patient's home setting if at all possible.

Wayland Marks is a geriatric physician and a Fellow of the American College of Physicians.

Link to full article:
Facing the End of Life