A wise man lives as long as he ought, not as long as he can. – Seneca
Greetings from God’s waiting room, also known as south Florida, where I am currently on vacation. It is a vision of the demographic time bomb ticking in this country. Due to great advances in medical care the fastest growing segment of the U.S. population is those over 85 years old and it seems like they are all here in the building I am staying in.
Why would anyone go to Florida in the summer? Well, I am cheap for one thing, and so is Florida in the off-season. It is also a lot easier to get a restaurant table in South Beach in July than in January. But mostly it is to avoid the onslaught of the new interns who are currently invading my hospital: hopeful, eager, idealistic, patient-killing machines. Don’t worry, though, dear readers, that is why we have attending physician supervisors. Just not this one.
I have been resting and rejuvenating far from the stresses of the ER, but as you know my work seems to find me wherever I go, never more so than when I am among the superannuated denizens of this part of the world.
As I got off the elevator yesterday, for example, I passed five paramedics with all their gear and a stretcher getting into the elevator I had just vacated. Ambulance attendants are such common citizens in my world that I scarcely gave it a thought, but the lobby was abuzz with questions and speculation.
Mike, the doorman, was presiding over the conclave of the concerned elderly residents gathered in the lobby. In buildings like this, the doormen know everything, and Mike was no exception.
“It’s the guy in 307. He’s terminal; brain cancer or sumpin,” Mike informed us in his heavy New York accent, so common in South Florida.
“They moved in about a year ago, nice apartment. Got a view of the pool and the ocean. It’s a shame really.
“Just got sick about two months ago. I dunno, some kinda tumor or sumpin. They been takin’ him back and forth to the hospice place. Takin’ him to the hospice place right now. I think he’s really dyin’ this time.”
The conclave cluck-clucked in sympathy; such a shame. Well, at least he is going to hospice, they murmured approvingly.
“Why does it take five guys and all that gear to move him to hospice?” my wife asked me.
I pointed to the city fire-rescue ambulance that was in the driveway, blocking in our car.
“He’s not going to hospice,” I told her.
“That is a 911 response ambulance. They only transport to the ER. He is going to the ER.”
“Why? What will they do for him there?”
“What we do.”
Since our car was blocked-in by the ambulance, we had a seat in the shade in front of the building. We had no really pressing engagement and it was one of those beautiful tropical afternoons with high puffy clouds and impossibly blue skies. There was something akin to a Zen relaxation taking over me. Being stuck in an EMS medical event with no role to play whatsoever was a weird and liberating feeling.
After about a half hour the medics bustled out of the building. The patient now had an IV in place, oxygen on and monitor wires everywhere. It was doing him no good. He had the gray, clotted complexion and the distant, glazed-over stare of the dying. As they bundled him into the ambulance he passed through a patch of brilliant Florida sunshine before disappearing into the gloom of the truck. I hope he felt it warm his skin.
The five medics got in the back of the truck, closed the doors and then nothing happened. The truck didn’t move; no one got out. Minutes passed, then ten minutes, then twenty.
“What are they doing in there?” my wife asked me. “Oh, my God! They are not coding him in there, are they?”
“It appears they are,” I replied.
I walked over to our car to see if there was any hope of angling it out past the ambulance, but it was stuck. There was a woman in the front seat of the ambulance who by her bored composure I had assumed was part of the crew.
She leaned out of the window and informed me in an officious way that they were going to be there a while. Then she returned her gaze back into the back of the truck where they were indeed performing CPR on the patient.
“My father is dying!” she further informed me. I expressed condolences and went back to my place in the shade.
As I sat there in a contemplative mood, my eyes fixed on the beauty of the day and the unmoving ambulance, I reflected on all I had seen of death in my long career. Eventually the ambulance moved off in a blaze of lights and sirens. The patient died that afternoon in the ER.
Here’s what I have learned from much time in the company of the dying.
When my time comes, leave me on the balcony of 307, with a nice view of the pool and the ocean. Let my last human touch be a loved one clasping my hand or caressing my brow, not a stranger crushing my sternum. Let my last sounds be parakeets in the palms or my own snoring, not sirens.
I have heard enough sirens in my life.
Dr. Robert, One of your best essays. So intelligent. You caught the NY speech of the doorman perfectly. Best wishes to you and Bernie and kids, Jim
Dr. Reiser,
A masterpiece! I am spreading this around the web. Profound combination of your wit and your wisdom.
I too have heard enough sirens in my life and like you, I will take the balcony seat.
Thanks for all that you do to make us laugh a little and think alot
-Monica
Sure! Most elderly patients with serious diseases who have no chance of a cure do NOT want CPR. Most lay persons think of CPR as something they try after you are already dead —after the heart has stopped.
But the request for NO CPR translates to DNR Code Status in the Hospital Chart and DNR Code Status is MISUSED to cap the costs of unreimbursed (by Medicare and the private insurers) treatments like mistakes, errors, over treatment and the complications thereof.
Why didn’t the specialist who was treating this man’s brain cancer level with him and ask for permission to put a DNR code status in the man’s hospital chart? —and then he wouldn’t have been coded!
IF DNR code status weren’t MISUSED, I’m sure most elderly patients with late stage disease would always want NO CPR but since the DNR code status is misused to shorten the lives of the elderly without their informed consent, whenever necessary, it is dangerous to have a DNR in the chart that can shorten your life without your informed consent.
I sure am not going to request NO CPR and want to retain my FULL CODE status until it is my decision that “I am better off dead.” I;m 86 and I can still enjoy the sun and the beach view and play bridge and see my children and grandchildren. I don’t want my life cut short as a means of fixing Medicare and preserving profits for the for-profit health care system.
Lovely essay, and thoughtful letter from Carol. I’m a baby boomer like Doctor Marquardt. and our generation will be clogging up the system for the next 30 years. I will say that the baby boomers as a rule take care of themselves which will hopefully cut medical costs to a degree. But we are mortal and the inevitable is what it is. I have spent my creer on the finance side of Emergency Medcine. And hate to admit it, but my first thought was that I hope the physicians at the ED, remember to document the time they spent providing Critical Care since coding for someone who is coding, so to speak is time based. but I digress. Carol, I have mixed feelings about your opinion on DNR. My brother in law was kept alive in a vegatative state for a year at extreme cost to the system because he had no living will, DNR etc. I’m not a lawyer, but I think we need to differntiate between what any provider should do in a Critical Care situation, and the extreme costs to the sytem in the last year of many lives. I also would like some level of control when that moment comes, but realistically many are in no shape to make a conscious decision.
Thank you for your response. Was your brother-in-law a Medicare or Medicaid patient?
I don’t think that patients are being kept alive in a vegetative state today (whether they have an advanced directive or not) and for the past many years if they have Medicare/Medicaid insurance because I don’t think Medicare/Medicaid reimburses hospitals/physicians for non-beneficial treatments
I think advanced directives are often misused to cap the costs of “indicated” treatments (not futile) that will NOT be reimbursed because of CMS protocols that punish non beneficial over treatments, errors and the complications thereof involved in the treatment of Medicare and Medicaid patients.
Overtreatment for the profit motive of the elderly/disabled could be stemmed or stopped if treating physicians (the specialists) were mandated to seek INFORMED CONSENT for either Curative Care OR Palliative Care from their elderly/disabled Medicare/Medicaid patients with serious illnesses and cancers.
Certainly, the treating physicians should have the legal obligation of providing an educated diagnosis and prognosis based on the neutral statistics provided by the academics who provide diagnostic and prognostic data for the medical profession. Patients and legal surrogates who are provided the hard facts and neutral statistics concerning their terminal illnesses will generally ELECT to die on Hospice and consequently save the government and their private partners, big insurance, the expense of dying in expensive ICUs and CCUs in our acute care hospitals.
Hopefully, the baby boomers will NOT let the for-profit clinics and incorporated for-profit physicians’ clinics continue to OVER TREAT for profit and then UNDER TREAT for profit (cut lives short) when CMS fails to reimburse for any further treatment. Hopefully, the baby boomers will want their autonomy to be protected and will want to reserve their right to determine when they are better off dead because they are “NOT DEAD YET.”
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