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#2: Having the Conversation

Welcome to the second episode of the Medical Narratives podcast with Dr. Michael Gordon. Dr. Gordon is joined by his colleague Dr. Michelle Hart to discuss Having the Conversation.

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Morning, my name is Dr. Michael Gordon and I'm one of the contributors to this new enterprise of podcasts in healthcare for the older population.

This is the second of what will be a series of podcasts and I'm fortunate today to have a colleague who once upon a time was a student who is going to join me in the discussion of what I often call having the conversation.

So I'd like to introduce Michelle Hart who's an attending physician in the department of community and family medicine at Baycrest Geriatric Health Sciences and I've worked with on and off for many years and I think what you'll hear from her is a very important perspective on the concept of having the conversation. Good morning Michelle.



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Dr. Michael Gordon recently retired after a fulfilling career as a geriatrician that spanned 56 years, 44 of which he spent working at the Baycrest Center in Toronto. He is Emeritus Professor of Medicine at the University of Toronto. Dr. Gordon is a recognized ethicist and a thought leader on all topics of care of the elderly and end-of-life decisions. Currently, Dr. Gordon provides part-time professional medical consulting mainly in the domain of cognition and memory loss.

#1: The Launch of the Medical Narratives Podcast

Welcome to the launch of the Medical Narratives podcast with Dr. Michael Gordon. Your go-to source for discussions on important issues in medicine and stories from real patient-physician encounters.


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RS Welcome to the launch of the Medical Narratives podcast with Dr. Michael Gordon. Your go-to source for discussions on important issues in medicine and stories from real patient-physician encounters.

My name is Regina Starr and I'm the Managing Editor for and the Journal of Current Clinical Care, the home of the Medical Narratives podcast. I am pleased to introduce the host of Medical Narratives podcast Dr. Michael Gordon.

Dr. Michael Gordon recently retired after a fulfilling career as a geriatrician that spanned 56 years, 44 of which he spent working at the Baycrest Center in Toronto. He is Emeritus Professor of Medicine at the University of Toronto. Michael is a recognized ethicist and a thought leader on all topics of care of the elderly and end-of-life decisions.

Michael is also a prolific writer and a masterful storyteller. He is a regular contributor to the Journal of Current Clinical Care and he will be hosting his own channel within the soon to be upgraded Health Plexus where all of his work will be organized in a curated section.

I've had the privilege to work with Michael the past 10 years.

Hi Michael, I am so excited for the launch of this podcast. Congratulations on this new venture. Welcome.

MG Thank you very much for inviting me.

RS Pleasure.

Telling stories is your thing, so our listeners would be interested to know how you chose geriatrics as a specialty when as I understand, it hardly existed in Canada or the United States at the time you went into it.

MG Well I can say honestly that I didn't choose geriatrics. I've been asked this question many times, I could say that geriatrics chose me and it was like so many things in life, happenstance. I studied in Scotland where indeed we had a geriatrics as part of our clinical experience and I can say that two of my favourite clinician teachers at the University of Saint Andrews Dundee campus were in fact geriatricians. They were marvellous people and it was clear to me in my young medical student days that they were very caring people, but they were absolutely fabulous clinicians and I could say that I learned how to percuss a chest properly from one of them. He played the chest like a drum. So geriatrics found me and it was a collection of events that led me into the field and I wasn't planning to do it in any way, but when the opportunity came up I decided to take advantage of it and literally within a week of acting as a consultant to Mount Sinai hospital for patients potentially going to Baycrest for transfer I fell in love with the field and have been in love with it for 44 plus years.

RS Fantastic. Beautiful. In fact, Mark Varnovitski, who is the publisher of Journal of Current Clinical Care and, he shared a story that he heard from another giant in the field, and another contributor Dr. Barry Goldlist, that you hold the number one geriatric specialty certificate in Canada. Is that true?

MG Well, it's true, but again like so many things it's not as if it was exceptional. I mean it wasn't planned of course, it was an accident of fate. At the time of the first exam there were only I think 10 of us eligible by the criteria and of course the criteria could not include formal training in geriatrics because that didn't exist in Canada and all the applicants as far as I recall none of them had formal training in geriatrics so we were you might say grandfathered in to just take the exam, a written exam, and an oral exam, and the person who actually examined me was a geriatrician, but from Australia and they already had geriatrics, but in any event we took the exam and when we got the Royal College certification there were only five of us who got the certification and as it turned out I was the lowest on the alphabet, G, and because I was the lowest on alphabet I got the first certificate. Well it sounds good, I mean it would have been one of the first five, but it sounds good and I know that my places of work love to say that I was the first certified geriatrician in Canada which happens to be the case, but not because there was something extraordinary about me the first five of us in fact were the pioneers.

RS Fascinating. In fact, my grandmother was the first geriatrician back home in Odesa.

MG Oh really.

RS Yes.

MG How about that.

RS And when she came to Canada, she volunteered at Baycrest for many years.

MG Oh I didn't know that. Isn't that wonderful.

RS So there you go, we have a connection.

MG Yes, well I always say, you have to be careful about making connections and sometimes when I'm talking to people because I like to hear their stories, I say we're going to stop now I can't afford another relative.

RS Well my grandfather on my mother's side came from Latvia with the last name Gordon.

MG Wow, then we really are.

RS So maybe we are Michael.

MG Because those that came that my grandparents came from Lithuania and of course Lithuania Latvia are neighbours and the name was an actual Scottish name that was adopted by Jews who lived in the shtetl Aniksht was named and they took the name because Peter the Great, boy it's in terms of current history, Peter the Great hired a Scottish mercenary by the name of general Patrick I think Patrick Dennis Gordon who fought for him he was in those days mercenary troops and at the end of the wars in the Baltics. People took the name Gordon when they had to during emancipation and they did it because general Gordon became a favourite of the Czar and it was a way of honouring the Czar and I when I lived in Scotland and studied there I tried to look it up and I found the reference to that story. In the history book of Russia and my grandfather when I asked him I was about I don't know 11, 12 years old what was our name before? he said before what? I said well before it was Gordon because most of my friends had names that were changed from Aski and Ozovitz and whatever and he said my great grandfather was a Gordon so it's always been Gordon.

Wow. So maybe indeed you have to find out because if it was Latvia and Lithuania I mean it was walkable almost.

RS Yes maybe we will. I'll ask my mom about that.

MG Yeah.

RS So I want to ask you, we just lived through two years of a global pandemic yes before the pandemic the medical profession was revered, however, during the pandemic we saw the mental, the physical stress, the amplified dangers for healthcare professionals who were on the front lines. Do you feel that the pandemic may have somewhat dulled the attraction of medicine as a profession for young people?


MG Oh the pandemic is so complex and you know it's funny I always say to people I'm not a spring chicken. I've been through in my teens, the polio epidemic and I remember as a teenager in my neighbourhood we all wore camphor around our neck. When I tell this to people they laugh. You say why camphor? The whole place smelled of camphor we you know spelled of camphor. It's because it was thought that camphor would keep the virus away. Remember the virus this is early days of pre- virology so we walk camphor and I mean you go to them if we went to the movies which was not something you did lightly, all the newsreels showed people in respirators, iron lungs in gymnasiums, in amphitheaters, because there were so many of them and then of course when the vaccine came out first salk and then sabin it it just changed the world, it changed the world, and then I also lived through a couple of influenza epidemics, the H1N1, and the Asian it was called of course the Asian flu and I was a teenager and I was uh no I was a sorry I wasn't a teenager, I was a young adult, no no I was a teenager, and I stayed at a friend's house because my mother was working and I was really sick I was like in bed for 10 days. So I've been there and because I'm old enough I've watched various infectious diseases.

I can remember whooping cough cases and it was awful. Anybody who says that they don't believe in vaccines, to see a child whooping is painful. So the pandemic changed many things in medicine. I mean the fact that they were able to turn out a vaccine in such a short time is really a miracle of modern virology and vaccine chemistry. It was unbelievable because usually it takes years. What we learned, many things we learned, but what we learned in the field of aging was that in a particular those in long-term care facilities nursing homes and retirement homes suffered especially not just because they were prone to getting the infection and when they did they often got very ill and died, but the places they lived seem to be almost facilities that caused the spread of the disease as if it was an incubator. I mean these people were living in a common space, the healthcare staff were stretched, many of them knew very little about proper precautions. I mean precautions for infection have always been a challenge to especially nursing and just watching somebody and I remember the SARS outbreak because we were closed down at Baycrest. All the hospitals were closed down, is watching them getting in and out of their gowns and their masks and their helmets and whatever is really quite a strain. So that the older individuals in these facilities really suffered, but the main thing besides the illness, which was real, and a high death rate, and I experienced this also on a personal level was the sense of isolation. Isolation, loneliness, depression, people couldn't visit. I can remember visiting somebody who I know very well and she was looking out the window of her apartment in a retirement home and we were looking up and waving and it was like some of the television programs that showed and it was painful because not only could she not see her family, within the building they decreased congregation, meals. I mean it really was when you think about loneliness is a terrible thing and we know in even in Britain they sort of started a I don't know if it's a regulatory committee or something to deal with loneliness, legislation to deal with loneliness because that becomes part of the epidemic of Covid, but any other illness that affects the risk of people living in congregate dwellings.

RS Yeah, it was very difficult the past two years and we have aging parents, the same thing we weren't able to see them. The grandchildren weren't able to see their grandparents. Very difficult.

MG Yes, I know this one person who actually had a couple of grandchildren, no great-grandchildren, births of their grandchildren, could not see them until they were almost six months old. You know I mean they got pictures and you know nowadays you can take a picture anywhere in the world. They got pictures, but that's not the same.

It's not the same. Of course the Zoom meetings and the you know, thankfully the technology was there the past two years because we obviously 1918 was different, but it's not the same, the human contact, seeing people, hugging, it's just not the same.

Yes, no hugging. I mean it's funny I've become used to Zoom, almost everybody's had to and I know many of my colleagues, especially at Baycrest, but elsewhere I'm sure, you know try to do their medicine over Zoom. Some of it can be done. Certainly the talking part.

RS Yes, but how do you diagnose an internal bleed over Zoom?

MG Well that's hard emergencies are hard and for emergencies the fact is you got to get dressed up in all that paraphernalia and anybody who worked in the emerge or the ICU knew you looked like you were going to outer space.

RS Yes.

MG And it's funny because I was a lover of the, even though I know a lot of people criticized that, Grey's Anatomy it was really up-to-date when they got to the Covid epidemic, they were all in spacesuits. Yes, well it's hard to be personal in the spaces I mean I find that even with masks and I'm pretty good at recognizing people just from their eyes, but sometimes that every now and then you see somebody you think I know you who are you and then they take off the mask say oh and you know it's very hard to develop you can't see facial movements. For people who, for example, are hearing impaired people don't realize that all of us do some lip reading, it's automatic. Anybody with any hearing impairment does a lot of lip reading so if you've lost the lip reading ability because of a mask and you're hearing impaired and you're not wearing it I can tell you hearing aids are sometimes very difficult to accommodate to. They can be a mixed blessing, background noise, whistling, and you know I have a lot of older people that it was a real struggle. One to get them accept the hearing aid and then to use them, even though we know that hearing aids are good for you, especially if you've got cognitive impairment. They enhance the ability to understand. I used to say when I was negotiating with a patient who didn't want a hearing aid, I'd say you know if you don't hear it, you can't remember it, and I've seen people who in fact when they did finally have some hearing augmentation, their memory impairment became less severe.

RS Right, so tell me, would you recommend to a young person to go into medicine today?

MG Absolutely, I'm a great proponent of medical careers. I think medicine and it's not fair, I know people who love the law, and love engineering. My father was a fabulous engineer and I learned a lot from him. I even went to an engineering high school because at one point I wanted to do engineering, but medicine is the most satisfying profession one could imagine and I know people who don't like it for various reasons, but if you're interested in people and I'm not just talking about altruism. I mean people say oh I just want to do good. Well sometimes medicine is not so dramatic. I mean saving a life is something special and I can remember the first few cases when I walked out of a you know hospital room thinking I saved a life and I could remember in Scotland the first diagnosis of meningitis I made in a infant. It was not a very fancy hospital it was simple, but I looked down the microscope while this stuff was being this central spinal fluid was being cultured I looked down, I did a gram stain, and there they were and I think it was H. influenza and in those days the antibiotic we use was Chloramphenicol. Now you can't use and Chloramphenicol for all kinds of reasons, but that's a whole other story. But I can remember walking out of the ward and say my G-d, I saved the baby, I saved the life. So medicine is marvellous. It's marvellous for the excitement of medicine, but the best part of medicine is people. The people you meet, the people you remember, the people you talk to, the stories you hear. I'm a big believer in stories.

I'm a writer as a I can say another profession. I love stories and I grew up with a grandmother actually we didn't have a lot of money so I shared a bedroom with my grandmother from Lithuania and my sister and a pet white rat and my grandmother told me stories and I heard all these stories about her growing up because she came to America in her mid-teens. Growing up in Lithuania having Russian cossacks coming through the village and killing people and her hiding in a potato cellar and I heard stories about the early days in the garment profession in New York and that terrible she was a witness to the triangle fire, where the seamstresses were locked into the factory and died. I mean it was marvellous stories and I've always been interested in stories and anybody who knows me, knows they have to be careful of course if they ask me to tell them a story what they're gonna get is a story, and my kids I mean they're I have wonderful children and sometimes you know I'll be telling them something and they say oh dad I know, I know, and I once had a conversation with my eldest daughter of my second marriage, Talia, who by the way is studying to be an anthropologist. Well she is because she has her Masters, but she's doing a PhD and I was telling a story, we're actually on a road trip but I was telling you a story started she said dad I know, I said you know my telling a story isn't so much that you don't know it, but it's important for me to remember it because that story is meaningful for me and sometimes I'm you know watching a movie I'll be asked if I like the movie and I'll say yes and the person says well it wasn't a very good movie I said, but it was for me because it brought back memories. It brought back stories. I made reference I know I can tell what a good movie is, but if the movie happens to take place, for example, in Scotland I enjoy it just by listening to the accent, you know. So I love stories.

RS True, true I do too and I guess that's another thing that connected us. I enjoy your stories and reading your narratives every month. So tell me what are your plans for the podcast? What topics do you think you'll cover?

MG Well, you know there are so many topics one could talk about. First of all, the great thing about geriatrics which is one of the reasons I enjoyed it, separate from the people business, is geriatrics has everything that internal medicine has. That's why you have to do internal medicine first. I mean it's a long haul, it's as long a haul as respirology, cardiology, whatever because you have to do your internal medicine so you have to know your internal medicine and then you do the geriatric component, but the patients you're seeing in a sense you know as a cardiologist and you see old people they have hearts so you've got geriatric cardiology, but in geriatrics you have geriatric everything. They have liver disease, they have GI disease, they have abdominal disease, and the real challenge is understanding the whole of internal medicine with the special components and nuances of geriatrics. I mean examples like and I've seen these cases. I feel sometimes like Jimmy Durante, I've got a million of them, I've got a million, stories of somebody who's come in you know who's a bit confused and they have mild dementia, but they get very confused and I used to see this a lot at the General Hospital I worked where the nurses would say post-operatively, oh mr so-and-so is confused they had a surgery, they must have had a stroke, and my little dictum when I'd see, no you have to think they didn't have a stroke what else could they have that makes them confused. Well one of the most common I mean this is bread and butter geriatrics is they have an infection, a post-operative infection. The only problem is they may not have a fever, in fact, what they may have is only confusion, a dropping blood pressure. So you have to understand the nuances of, for example, infection in the elderly and I mean I've seen so many cases of older people with conditions that are easily missed because the symptoms are not I mean it's known that older women, women in particular, but older women often have heart attacks without manifesting the typical symptoms. So you have to be aware that any change in mental status might be the caused by some medical condition which the condition itself is common, but the presentation is uncommon. So you know, it's such a broad field that it's absolutely marvellous to contemplate it and the learning of geriatric components of internal medicine, nuances of internal medicine, are just challenging and wonderful and satisfying.

RS Do you plan to invite any guests on your podcast?

MG Yes, I would be happy if there was an opportunity to speak to somebody, either within the field of geriatrics or within the field of family medicine with a large patient population of older people and in the real world not unless something special happens, we're not going to have enough geriatricians to look after all the older people, it would be impossible, and I'm not sure it would be a good use of the resources because family medicine especially if somebody's taken the special extra year of care of the elderly gives them the ability to do most of the important work in the care of the elderly and the geriatrician could be the person who's a resource for program development, for educational programs, and to help family physicians including those with care of the elderly expertise to help solve some of the problems, and some of the problems are not purely medical problems, they're psychosocial problems. I know I've heard this from doctors I've worked with over the years, they get upset with families, you know that are asking too much, or asking too many questions. Isn't part of their repertoire and it's something I have to learn as a care of the elderly doctor as you have to ask what you may think is a very simple question to answer, but it isn't I mean most people don't know I'm dealing even as a family member with issues related to family members that have problems and I hear family members talk oh they've had this, they must have had that, and I have to be very careful because you don't want to get into family dynamic conflicts. To say well you know in my experience and whatever, but you know that's the story so as a geriatrician there's a lot to offer to the patient population, to the medical health care population and I know that in my career one of the things I love to do is teach and especially teaching non-medical people. I did a lot of in-service in various organizations for nurses. I have an interest in ethics so I also can bring that to the table because a lot of the problems that come up in the care of the elderly are what we call ethical. What's the right thing to do, conflict over decision-making, who's in charge of decision-making. I mean these are conflicts complex issues, but they're very important.

RS True and how often do you plan to drop these episodes?

MG I have to see how much energy I have. My commitment initially is every month, if I find that I can get all my resources together, I might do it every two weeks. It's you know it's demanding. I like it, but it still takes energy and creativity to do it well.

RS Of course, I know that you are an accomplished author of a few books. If you recall a few years ago we reviewed Parenting Your Parents.

MG Yes

RS Excellent resource for families with aging family members. Are you currently working on another book?

MG Well as we say in the Catskills, funny you should ask. Well actually because I've written so many narratives pieces on medicine, ethics, social medicine issues, personal, human issues, and a lot of them were published in the Health Plexus Journal of Clinical Care as well as other journals. I decided to try to pull them together as a compendium of articles and I fortunately found a lovely student to help me. He wants to study medicine, but this was an opportunity to get involved with editing and organization he says he's learned a lot of medicine from it, that wasn't the plan, but he's a lovely guy and i'm putting together these articles together into a book. It's not quite a memoir. I wrote a memoir called Brooklyn Beginnings a Geriatrician's Odyssey which actually is being updated as well, and I hope to have this new book out. I'm waiting for some final issues to be resolved, but I hope to have it out certainly within this year and then I'm working on my previous three most recent books which was Brooklyn Beginnings a Geriatrician's Odyssey. Late Stage Dementia, which is a book to help clinicians and families deal with the end of life and the end of activity with people who suffer from dementia Alzheimer's disease etc. and then another book which actually I've just finished rewriting and I've submitted to the publisher they did the first edition it's called Moments that Matter and this I decided since I was interested in ethics and often when you're talking to families you try to bring an ethical concept because most people in quotes "want to do the right thing" and as soon as you say the right thing it's not just a clinical right, it's a right that makes them feel that what they've done has been the proper thing for their family member. So I wrote that one and it's just in the process of being reprinted as a new version and so I got a lot on my plate over the next I'll say six months to a year, but I hope that my new book, my latest book will be out by the end of the year.

RS Excellent. Look forward to that. I can attest I have read every single medical narrative and some days I feel like I could become a doctor.

RS So my last question. I know that you have a lot to share with our listeners in your upcoming episodes, however, just to give a quick sample of what to expect, what advice would you give to somebody who is caring for an aging person, a relative with many co-morbidities, even possibly dementia?

MG There are many, many issues. I think that one of the most important and I've written about this and you've read it. I call it having the conversation and I actually went through it with my late father. Having the conversation which means actually discussing openly, not by nuance, not by beating around the bush, what is it that no not everybody knows the answer to their own wishes what would you like if and I know people say oh we can't talk about it it's too morbid. Well it's not morbid until the time comes when you have to make a decision and sometimes children say well I don't really know, I don't know what they want, and I just went through this I just redid my advance directive with my lawyer, but I was just tuning it up a bit, but the idea that you want the person and my family certainly knows, to understand what they would want if, and the ifs can be many. You can't imagine what's going to happen, you know you say well you know when I get old enough I'll die, yeah and if you break your hip and can't walk anymore then what? Does that mean you'll be allowed to die, you'll be in a nursing home, you want rehab, you want to be at home? What about, I have one little scenario anybody who's worked for me says well what if you can't eat anymore? Well you want us to put a feeding tube in you? No, I don't want a feeding tube. So well what do you want? I want to eat, but what if you can do because it's dangerous and they say well if that's the case maybe I'd rather die, and I'll let the family listen. I said listen you have to understand because the person may not be able to make a decision at that time and you the family member becomes the decision maker. So having the conversation and I had it I can remember with my late father after my mother died because the fact is she had a terrible death, unexpected, with all kinds of side effects and we had to decide in many ways on the spot and when my father became ill and my sister who was wonderful looking after him, we had to decide because he got sick and he was going to be going up to the ICU and my sister said you know when they said what do you want to do and she said everything and I said wait that's not what he told us. Remember what he told us and we were able then together say no let's do this and this and if he has a cardiac arrest that's it because that's what he told us and you want to know that without feeling guilty. Anyway, I think that's a whole area of proper conversation and that would be one if there were somebody else who wanted to participate I'd be happy to, if people wanted to send in questions to be posed to me. I'd be happy, however, it works, but the issue in the subject is very important.

RS Yeah for sure and we will dedicate an episode just to these questions because they are so important. So that brings us to the end of this podcast.

Thank you so much for listening. Thank you, Michael. Please consider giving us your reaction by pressing the applause icon. Feel free to post comments or your questions to Dr. Gordon in the comment section below and press the follow button to follow Dr. Michael Gordon. Thank you so much.

Dr. Michael Gordon recently retired after a fulfilling career as a geriatrician that spanned 56 years, 44 of which he spent working at the Baycrest Center in Toronto. He is Emeritus Professor of Medicine at the University of Toronto. Dr. Gordon is a recognized ethicist and a thought leader on all topics of care of the elderly and end-of-life decisions. Currently, Dr. Gordon provides part-time professional medical consulting mainly in the domain of cognition and memory loss.

Abandoning Treatment Due to Age Alone


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When caring for older adults with comorbidities, especially those at the extreme upper limits of life, it may be easy for providers to lessen the intensity of their curiosity and medical investigation. For some older individuals’ chronic conditions, the odds of a positive outcome may seem too distant or the patient’s discomfort—or, in many jurisdictions, the financial burden—may act as a barrier to the pursuit of answers.

Sometimes it can seem like the answer itself is unlikely to result in any meaningful benefit to the patient. When providers see an older patient with what appears to be a chronic condition, who is physically and mentally declining, it is not unusual for the provider to just accept it as a natural consequence of extreme aging. Patients themselves and their families are willing to accept futility as well, even if reluctantly, when the “verdict” comes from a physician—especially if it is a “specialist.”

One such example of this kind of case—what might be called “beneficent ageism”—occurred in my ambulatory geriatric practice. The patient was 95 years old when I first encountered her in my office accompanied by two devoted daughters who were committed to her care and fixated on the task of trying to allow her to live out most of her life in the communal home (one daughter lived with her with her family and the other lived close by). They were truly doting children.

The patient’s main complaint was cognitive impairment, and she fit the usual criteria for mild dementia with a range of vascular risk factors—she actually was started on and responded modestly to donepezil. With this positive result, it became clear that she had other bothersome symptoms that had, over time, been attributed to her age. For example, she became easily short of breath and had been to emergency rooms (ERs) over the years with what had been construed as heart failure due to a mixture of hypertension with (what seemed to be) mild chronic lung disease of uncertain etiology. She was maintained on the usual collection of vascular enhancers and pulmonary puffers, which afforded her some comfort with the acute episodes that had resulted in ER visits—an extra dose of furosemide and some intensive bronchodilator therapy.

She also had modest anemia, which had never really been looked into and seemed merely incidental. It was treated intermittently with blood transfusion for which no clear etiology was found—she had normal blood levels of B12, folate, and iron but a moderately low ferritin for which iron had been given with minimal benefit to her hematological parameters.

At the age of 97, I consulted with her attending physician and specialists to see what the cause of her anemia was and whether it could be possible that the degree of anemia might be compromising not only to her cognitive function but to her cardio-respiratory function. The daughters agreed that after blood transfusion she always seemed better in terms of her cognition and “breathing,” whereas, when the levels began to fall, she would often be short of breath at rest with little in the way of exercise reserve. Despite a number of enquiries, I could not convince any of the other physician specialists to agree to have her referred to a hematologist. Having heard about the possibility of a bone marrow biopsy with a hematologist, the daughters were even reluctant to intervene with an investigation that might cause her discomfort. I explained the procedure (having had a few myself for personal medical problems) and said, if by chance something were found, it might respond to medication that could stimulate the blood-making process of the body. The hematologist referral was eventually accepted with reluctance by the patient and her daughters.

One day a fax came through with a letter from a nephrologist and the hematologist indicating that they would forego an actual bone marrow evaluation to avoid discomfort but felt that the patient’s minor renal impairment combined with her other chronic disease burden might respond to therapy with erythropoietin.

About 8 weeks later, the patient and her daughters came into my clinic, early for the appointment as usual. When I saw them in the waiting area, they waved at me, and I could not help but note that the patient was not huffing and puffing as I had previously seen her—even while sitting. When their turn came and I could see her close-up, I saw that her skin color was more robust than usual, that she indeed was not huffing as she spoke to me, her cognition was at least as good as previously, and, if anything, the content of her speech and language appeared better. The more communicative daughter handed me a sheet of paper on which numbers were written. “You would not have received these yet as they are only from yesterday, so I copied them down for you—unbelievable.”

Indeed the numbers were impressive with a hemoglobin level that had gone up almost 20 points from the previous 6-month average. Her skin color and conjunctival color was close to normal. But most impressive was her breathing pattern and the animation of her speech. The daughters were beside themselves with glee and the patient thanked me—by name—which she was not always able to do.

There is an adage that goes something like “age alone cannot be used to determine the likelihood of usefulness of treatments.” While it should be understood that age is an important component of decision-making, if the investigation and treatments are not onerous by nature, they should not be discarded simply because of the high-age factor. Indeed, nothing should interfere with a thorough analytical review of possible diagnostic and treatment options for each individual a medical provider encounters.

This article was originally published online at

Why Families Should Consider Forgoing CPR


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It happens a few times a month: I get a request for a meeting with a family struggling whether or not to provide a do not resuscitate (DNR) order for a frail and aged family member. Often the patient has dementia, and, therefore, the decision falls to the formal substitute decision maker (SDM), in keeping with the Health Care Consent Act in Ontario (and comparable legislation elsewhere). It's an enormous burden for many families, and the decision to comply with the request for a DNR order is often fraught with great emotional pain and reluctance.

As a health care provider and ethicist involved in conversations with families, I often hear the refrain, "I just can't bear the thought that I am responsible for my father's death. He was such a fighter. He survived the Holocaust and now this, giving up like this. I just can't bring myself to do it." There may be more than one child, and sometimes they share responsibility of being the SDM, which means both parties (or more) must agree, which could lead to family conflict and strife.

The ultimate question for families is what does CPR actually offer to their loved ones, and does withholding such intervention through a DNR order make the children (assuming they provide the order) complicit in the death of their loved ones, which is a heavy burden to carry.

Many may not realize that the development of CPR in the 1960s was meant for a very select group of cardiac arrest victims who were otherwise usually well and whose hearts suddenly stopped, but had the wherewithal and cardiac reserve to withstand CPR, which, if successful, returns an otherwise relatively healthy heart to its intended pumping function.

Over time, the criteria for implementing CPR expanded to less-well individuals, with some occasional successes. But studies of various populations found that frail elderly individuals—those who fulfilled in most jurisdictions the criteria for residence in nursing homes—did not have the heart or bodily reserve to withstand the rigours of CPR. Rather than having a "cardiac arrest"—the sudden, unexpected cessation of heartbeat in an otherwise medically intact person—what occurred was in fact death, rather than an "arrest."
What does this mean for frail elders in nursing homes, since immortality is not part of the medical repertoire? One is going to die from a combination of age and all the physical and neurological conditions that afflict those who live long enough, which often include dementia. It's not that dementia itself is the barrier to successful resuscitation. It's that dementia in the frail elderly is usually a marker for a collection of problems that make it most unlikely for someone at the end of life to survive and recover from what is in many ways a trying and almost assaultive intervention whose outcomes are in most cases very bleak.

The other concern about all the attention given to CPR and the emotional turmoil about deciding on a DNR order is the elimination of the very human activities that might otherwise occur when death without CPR is expected and anticipated. The intrusion of CPR is often accompanied by the transfer from a nursing home to a general hospital. This disrupts the potentially peaceful passing of a loved one, which is sometimes associated with prayers and other rituals, depending on cultural or religious practice. Holding hands and personal expressions of love are replaced by the often traumatic intervention of strangers and technologies that distract from the humanity of what in most cases will be the death of the person in any event. CPR creates a medically focused event that sacrifices what may be the last chance for a family's expression of humanity and love.

This article was originally published in the December 22, 2016 issue of the CJN.

Further Reading

  1. Gordon M. Assault as Treatment: Mythology of CPR in End-of-Life Dementia Care. Annals of Long-Term Care: Clinical Care and Aging. 2011;19(5):31-32.
  2. Schafer A. Deciding when life ends. The Ottawa Citizen. February 8, 2008.<redir.aspx?REF=LbTtdqvjyWGkMsaVANVz8Hs_unV55CS3e5aUspFEIwWSW4D-sTnUCAFodHRwOi8vd3d3LmNhbmFkYS5jb20vb3R0YXdhY2l0aXplbi9uZXdzL3N0b3J5Lmh0bWw_aWQ9NmFmODZiNzYtMzJiYS00YzQxLWIxMWMtMjJkZjc3NGQ3NGQ0> [3]. Accessed January 13, 2011.
  3. Gordon M. In long-term care, the "R" in CPR is not for resurrection. Ann R Coll Physicians Surg Can. 2001;34(7):441-443.
  4. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;36(1):22-31.

Should We Keep Meeting Like This?—The Place for Reunions


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Reunions are unusual and sometimes bizarre phenomena. It is curious that people seem to be drawn to meeting over periods of many years or even decades with people that they may or may not have been close to during some period of their formative years of education. Think about the likelihood that at a high school reunion, you might meet more than a few people of significance in your life or with whom you have even the remotest interest in knowing what they have done during the intervening years. For university or post-university reunions one might imagine there might be a greater chance of congruence of life experiences and the possibility of a more compelling reason to know what life has done to the group individually and collectively.

I recently attended my “50th” medical school reunion in Dundee Scotland. Though born American I decided to “study abroad” as a means to satisfy my desire to travel—something I recognized from a 6 month stint as a university student wandering through Europe in my “junior–3rd year”. That 6 month stint stirred my determination to study overseas and as it turned out I was fortunate enough to be accepted into an English language first quality medical school in Dundee Scotland, which at the time was the clinical training resource to the renowned University of St. Andrews. It subsequently separated from its “mother ship” and became the University of Dundee that is the home of what has become a highly regarded medical school.

I have not missed any reunions, which started with the 10th and have continued every five years since then. At the 10th our guest speaker was our chief of medicine—Sir Ian W. Hill who was at that time the physician to the royal family when they were in Scotland that usually occurred at one of their favourite retreats, Balmoral Castle, with its beautiful surrounding hills and woodlands. Sir Ian, who was one of the greatest lecturers I have ever encountered—able to mesmerize a lecture hall full of medical students with his stories of illness and disease--cautioned us to stop meeting after 50 years as there might be few participants because of death and illness.

The reunion was a treat—it was in Dundee rather than as previously in St. Andrews; my youngest daughter joined me, having been at one about 15 years earlier and it fulfilled what reunions do—reminded us of our roots, of our history and gave each of us (we were only 25 classmates out of a class of 70—plus in many cases spouses)—a chance to reminisce about our lives and what seems to be the core of the attraction of reunions, to recount our recalled and shared experiences.

Even though many of the same stories were shared at previous reunions, recounting the stories of escapades, travel, parties, shared flats, our idols and failures as teachers and sadly our classmates who had died in the interim period—the whole experience was a mixture of rollicking fun, uplifting narratives and sad recall of dear classmates who had left us—with this reunion having lost three classmates in the previous 6 months—ones with whom I was especially close.

Like many things in life that we do, there is no compelling explanation or objective benefit in a reunion—but since it seems to be almost universal among so many people, it must resonate with those of us who wish to and usually attend. Reliving and sharing our past, confirming our recollections and in some ways fulfilling the curiosity about “what happened to …..?”Although Sir Ian counseled us against going beyond 50—as we were preparing to leave, a small group of us, including myself, planted the seeds for perhaps the next—55th reunion—I hope so and hope I can attend.

This article will be published online in January 2017 at

Dealing with Family Strife


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One always hopes that as medical practitioners, we will be able to focus our attention on the medical issues faced by seniors and help families cope with the fears, disappointments and tragedies that are faced by loved ones in the midst of what are often life-altering illnesses.

Throughout our initial medical training, and most often during post-graduate training programs, the primary focus in general is: what is the "best of medicine" and what does "evidence-based medicine" tell us about treatment decisions and their ultimate impact on health, well-being and, often, the likelihood of death? This is particularly the case in the care of the older adult—whether in geriatric medicine or eldercare.

What is often surprising and baffling, especially to younger physicians, is the situation where the core of what appears to be the challenge in care provision is negatively tinged by what might be called family "strife." At times, however, a more appropriate term would be venomous, hateful actions—actions that ultimately will be destructive to the family fabric.

This should not be surprising to anyone who has even a modest understanding and familiarity with the world of literature—whether limited to English works, or more broadly including European or other literature.

Those medical trainees who have worked with me have in all likelihood heard me either seriously or humorously say, "If I were king, all first degrees would be in English literature." Or when there is a complex family dynamic playing out, I might say, "It's King Lear—if you have not read it ever or lately, read it or read it again—it's all there."
Sometimes I feel like that great American comic Jimmy Durante, who was quoted as saying, "I have a million of them, a million of them," referring to his often delectable jokes. According to an online biographical history, it has been said that "I've got a million of 'em" is what Durante (1893-1980) often said after telling a corny joke. Durante was credited with "I've got a million of 'em" in a 1929 newspaper story.

I say this when referring to complex family situations in which what appears to be the worst in human interactions seems to be playing out. Often the issue is related to money (or property), and if one is in a position to hear the story from all the parties, it often becomes clear that, for whatever reason, the pot has come to a boil at this juncture of life. This is usually because the flame heating the water that's not boiling has been on for what appears to have been many years.

Most of us know of such stories, hopefully not in our own families, but it is unlikely that there is a family who is not familiar with a "Lear-like" scenario in someone close to them. Greed, jealousy, hurtful memories, mean-spirited personalities, events that occurred—sometimes decades earlier—that were never resolved or left indelible scars are often the reasons cited for the enmity.

I have had the good fortune to observe that, on some occasions, especially when a parent, in particular, is dying, though it could be another relative, there is the possibility of repairing longheld animosities and bringing long-estranged family members back together. It does not always succeed, but I have witnessed the monumental efforts of health-care staff—especially those in social work, nursing and medicine, although any and all of the health-care staff can be key—in bridging the emotional moat that often separates family members.

It may not always work, but I believe it is always worth the effort. Living with the result of lifelong family strife is often disabling, and the scars that occur and that are left can have long-lasting negative effects on people's lives and their own abilities to have meaningful and binding relationships with their siblings and offspring.

This article was originally published online at


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Many older patients of mine have metal implants in their limbs following some form of reconstructive surgery. It is the age of the bionic person.

With so many "snowbirds" and with security metal detectors almost everywhere, there is often an expressed concern about whether having a metal implant in the hip or knee might delay you or lead to problems when you pass through airport or cruise security metal detectors.

I recently had a comparable experience when flying, which I do quite often. I had acquired a MedicAlert bracelet, which also is a common accoutrement of many older patients. As I passed through the security arch having already removed all my usual triggers (phone, wallet, belt, watch), the alarm went off—I realized that the Medic-Alert bracelet, whose clasp is such that it is very difficult to open, clearly for safety reasons, was the culprit. I mentioned it to the agent—who took his wand and clearly identified the source of the alarm, and when he finished the rest of the scan, he let me through without any problems.

I was curious and perused the medical literature on the subject, given the high prevalence of seniors with metal in their bodies—part of the contemporary miracle of modern medicine. I recall a time when severe knee and hip arthritis left seniors either completely immobilized or chronically racked by significant, often life-altering pain.
It is not that the surgery is "easy," and it's not always successful, but for many, it can have a dramatic and long-lasting beneficial effect. No less important than the surgery itself is that there seems to be a very flexible ceiling on age—with some very elderly individuals found suitable for surgery—depending on what other medical conditions exist.
Many of the articles that discuss the issue remark on a practice in the past, when patients with metal hardware in their bodies often provided the security agents with letters or cards attesting to their condition. However, it is now felt that these are not needed nor heeded, as there is no way of verifying the veracity of the author—and the backup metal detector or full body scan will do the trick more effectively and assuredly.

What most of the articles on the subject suggest is that the traveller should alert the security agent right up front about the issue rather than waiting for the detector to go off. I thought of having the clasp on my MedicAlert bracelet changed to one that could be more readily opened and closed but decided that the security of a bracelet that could not readily inadvertently fall off was more important than the minor inconvenience of a manual security scan.

Some things, we often say, just "come with the territory." Travel has become more complicated because of issues of security. There is no doubt that the recent tragic bombing of a passenger plane in the Middle East will result in either more intense scrutiny of travellers or some new directives on screening—just when things seemed to be easing up in North American airports.

Medicine has become more complicated because of novel treatments that, although life enhancing or life saving (such an internal heart pacemaker which also has metal wires), may cause some modicum of inconvenience at the security gate when people travel.

This seems to be a small price to pay to achieve both desirable ends—being able to walk unattended through a security gate after restorative surgery, and making sure that fellow travellers are safe in their travels.

Still, during those years when I was studying medicine all this would have been in the realm of wild imagination.

This article was originally published online at


Where's the Beef?


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I was sitting in a coffee shop next to table with 5 older women. I could hear one of them say to the group, "I am cutting bacon out of my diet—but I do love it once in a while". "Why are you doing that, one of the woman replied?" "I just read that bacon and salami and hamburgers can cause cancer—didn't you see the paper yesterday—it was also on the news last night—it is almost as bad as smoking cigarettes—who would know—I hope it isn't too late as I have bacon at least once a week on the weekends when we go out for breakfast."

It always amazes me how when something is reported in the media, the response ranges from hyperbolic concern by reporters and the public to complete lack of concern by others. It can be very hard for the public, and at times the medical profession to decipher the real implications of the many reports that focus on public health threats from the world around us. I have watched as items such as eggs, coffee, various fats and oils, alcohol, different types of exercise and where we live and what we breathe become the focus of notices to the public to either "beware," "take heed," "change practice" or "just stop what you are doing".

Some public health warnings are real and immediate and often due to the finding or some food item that is being eaten or prepared in "real time" that poses an immediate threat to consumers. A recent example is the warning and resultant steps taken by the restaurant chain Chipotle where at the time of writing, "More than 40 people have fallen ill with E. coli food poisoning after eating at Chipotle Mexican Grill restaurants in six different states…the outbreak expanded with new Chipotle-linked E. coli cases reported in California, Ohio, New York and Minnesota, the U.S. Centers for Disease Control and Prevention said."

This type of warning is reminiscent of those that are propagated by public health agencies during BBQ season reminding consumers to BBQ their chicken and hamburgers particularly well because of risks of E-Coli outbreaks—a ubiquitous bacteria that can be destroyed by proper cooking but may linger in undercooked or rapidly cooked meet where the necessary bacterial-killing inside temperature is not reached. In 1993 there was a serious outbreak in the Jack in the Box chain of fast-food outlets in the United States that resulted in hundreds of illnesses some of which resulted in chronic and serious illnesses—it had a profound impact on new standards for food preparation in the fast-food industry.

These warnings are different from public health warnings about eating habits—having watched the potential harmful effects of coffee come and go over the years, I was forever grateful that the final estimation of this almost universally consumed drink, is that it probably has more beneficial effects on health parameters than negative ones—for me coffeeophile a public health blessing: yet the European Union recently recommended against drinking more than four cups of coffee a day based on caffeine consumption. In contrast is the recent report that," Hold on tight to that cup of Joe—because it could save your life. New research out of the Harvard School of Public Health says lifelong coffee lovers could be at less risk of dying from type two diabetes, suicide, cardiovascular and neurological diseases. "We found people who drank three to five cups of coffee per day had about a 15 percent lower [risk of premature] mortality compared to people who didn't drink coffee," one of the authors of the study, Walter Willett, told NPR.

So what about the bacon, hot dogs, corned beef and pastrami? What about the BBQ steaks and hamburgers? Does everyone who is not an life-long vegetarian or subscribe to the Mediterranean diet run the risk of sudden death from a BLT or hot dog at their favorite ball game? That a recent study in the US reveals that 57% of American Jews eat pork in one form or another (—should not necessarily be interpreted as a sure sign of anti-religious drift or impending doom, but rather the way surrounding cultures and practices influence people of all ethnic and religious backgrounds.

The final message should be: Most things can be eaten in a moderate and balanced fashion, unless there are specific health-related concerns for an individual—more important than how much bacon, meat and pastrami one eats, is that the portions are in keeping with one's individual nutritional needs, that they are balanced with other non-meat foods, including vegetables and fruits and that they are prepared and cooked well Food is one of the most enjoyable aspects of life—we should not make ourselves obsessively concerned every time a new "warning" comes out about the dangers of life and what we eat—hang in there—likely the recommendation will change over time—take it all in stride- with a dollop of mustard.

This article was originally published online at

Make sure your Substitute Decision-Maker Understand the Rules of Engagement


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I have heard it many times, “ I am the POA (wrong use of the term—what they mean is the Substitute-Decision-Maker (SDM) or as is often used in the United States Proxy: the POA is in fact the document outlining the substance of the decisions that are being referred to). But that being said what the person, often a family member, usually an adult child is implying is that by being appointed the SDM (either through an advance directive (living will) or appointed by the legal system or as is the case in Ontario through the hierarchy of the Health Care Consent Act, they can make the decisions on behalf of their family member—often a parent—often one with a disease affecting decision-making such as dementia.

What many SDMs do not realize or wish to ignore is that their role only comes into being when the person that are ostensibly acting for is deemed to have lost their capacity to make decisions—that is to see is incapable using the legal sense of the term—unable to understand and appreciate the implications of their decision-making for what is usually limited to health care decisions—and as it is in Ontario, application to a long-term care facility.

What this often means is that SDMs sometimes try to control decisions of their family members who have not been deemed to be incapable, but choose not to get into conflicts with the family members that they know will have to depend on them in the future. I have witnessed situations where an older person admitted to a hospital because of a fall or an injury, but who is mending and able to return home perhaps with some help, is directed by a family member to apply against their real wishes to a nursing home. When for example a social worker asks the person if that is what they want and they say, “no” the family member is often incensed that the social worker is interfering with the “rights” of the SDM to make such a decision on behalf of a reluctant or even refusing parent.

Sometimes it is a matter of not understanding the law, or not respecting the person on whose behalf you under other circumstances would be acting. At other times it is an issue of control and the SDM is trying to find a solution ostensibly for the benefit of the person, but at times it is also for the benefit of the SDM in terms of the demands on their time and energy.

Sometimes it revolves around issues of medical treatment where either the patient refuses or wishes a treatment that the SDM wants the opposite—the result is often what appears to be an either bullying or blackmail by the SDM toward to person on whose behalf they are to be acting or at extremes to the physicians who are trying to follow the law and adhere to the capable wishes of their patient.

It is not easy at times to act in the role of SDM especially for someone you love—the way I often frame it is rather than being a “right” to be carried out by the SDM, it is in fact the “right” to fulfill the duty that one who is appointed as SDM to act on the behalf of a dependent or vulnerable person—that duty is one of the privileges of life and should be undertaken with the utmost seriousness and devotion that one can bring to the situation.

Any Reason to not Enjoy Sex if you are in a Nursing Home?


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A while back there was a headline in the New York Times about a well-known retired politician who was charged with rape for allegedly having sexual relations with his wife. This would of course not have been a story were it not for the fact that his wife was at the time of the alleged event living in a nursing home and experiencing cognitive impairment to a significant degree. The story as it unfolded was the result of her two adult children who were from a previous marriage bringing charges to her husband because it was felt that being afflicted with dementia and being deemed by her physician as “incapable” of providing consent to the intimate act, that he would therefore be liable for the criminal offence of rape.

Many who heard the story were shocked and astounded that a husband was not able to have sexual relations with his wife because she was living with dementia even though there was nothing to suggest that he was acting against her wishes or with force or coercion. The usual legal measure of consent was the one usually reserved for the giving of consent for a medical condition rather than for an act of sexual intimacy which had it occurred in the couple’s residence prior to her being admitted to the nursing home would not have resulted in what appeared to be quite a scandal.

As it turned out the husband was acquitted of the charges on what was in essence a technicality in that no one had actually witnessed the act on which the charges were laid and the evidence obtained was at best indirect. The importance of the case was not however lost on the legal profession and on those caring for those living with dementia. There were many who came to the defence of the intrinsic right of those whatever their medical conditions and their cognitive function to be able to participate in and enjoy the benefits and satisfactions of sexual intimacy whether at home or in a nursing home with those with whom they wish to share this precious physical emotional connection.

Maybe the time has come for people to express in the same way what they indicate as their wishes for medical treatments to those who will make decisions on their part that they wish to be able to participate in sexual intimacy with those that they have done so in the past or with whom they have indicated—whether in writing or communication—so that those perhaps who do not understand the importance of sexual intimacy or who have value systems that belittle the importance of such activities in one’s later life or when one’s cognition may not be “normal” can still enjoy the wonderful attributes of sexual intimacy.