Michael Gordon's blog

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 https://www.managedhealthcareconnect.com/blog/abandoning-treatment-due-age-alone

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. www.canada.com/ottawacitizen/news/story.html?id=6af86b76-32ba-4c41-b11c-...<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.
5. http://www.rmmj.org.il/userimages/408/1/PublishFiles/418Article.pdf

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 http://www.cjnews.com/

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 http://www.cjnews.com/perspectives/opinions/dealing-family-strife

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 http://www.cjnews.com/living-jewish/travel/do-metal-implants-hinder-your-ability-to-travel

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 (http://www.pewforum.org/files/2015/11/201.11.03_RLS_II_full_report.pdf)—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 http://www.cjnews.com/perspectives/ideas/wheres-the-beef