On a serious note: Discussing end-of-life care

Peter J. McDonnell, MD

He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.

If we can help our patients understand the wisdom of leaving a written record of their desires should they suffer severe medical setbacks, they might avoid the problems that can occur from having their health care guided by presumably well-meaning family members who might be educationally or emotionally ill-equipped to make sound decisions.

A physician friend asked, "You ophthalmologists take care of a lot of elderly patients, don't you?"

"We sure do," I replied. "In fact, in my medical school, only the Division of Geriatric Medicine sees a higher percentage of Medicare-insured patients than does my department."

My physician friend went on explain that she thought we ophthalmologists could help our elderly patients educate themselves about this topic. She recently had seen a number of sad examples of what happens when that issue is not addressed, and told me the following story:

A ninety-something patient with severe dementia recently had been admitted to her hospital with cardiac arrhythmia. The patient was a resident of a nursing home, and the cardiac problem recently had been detected. Left untreated, the patient would probably develop a fatal arrhythmia and hypotension and die a peaceful death sometime in the coming weeks to months. At the family's insistence, however, the confused and agitated lady was admitted to a hospital for a procedure to implant a very expensive cardiac pacemaker ($50,000 for the device alone). Because of her severe dementia and fear, she would require general anesthesia for the procedure, and physical restraints the rest of the time. Putting themselves in the position of this patient, almost all members of the health-care team would have opted to expire without the pacemaker, but the family members were adamant that everything possible be done to keep the patient alive. If she had left documentation as to her wishes, the group believed she might have been spared a lot of stressful medical interventions to preserve what was obviously a terrible quality of life.

"You ophthalmologists at least could leave brochures in your waiting rooms that interested patients could read," my friend said.

At first blush, it did not seem that end-of-life care planning fits within the ophthalmic portfolio:

"Ms. Jones, which is better: one or two? And would you want blood transfusions if you are severely ill and bleeding?"

"Mr. Smith, if you lapse into irreversible coma after your procedure, how do you feel about being kept alive on a ventilator?" "But doctor, I thought I was here for my regular Botox injection!"

We ophthalmologists know what it is when people lead lives little better than those of animals, incapable of any higher-order cognition. We have seen "Jersey Shore."