Aging in America

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Emergency physicians discuss end-of-life care
Grandma’s Chocolate Cake
When I was in residency, my grandmother already had broken the record for time in the nursing home: 10 years and counting. She was healthy – so healthy, in fact, that my dad was convinced she would outlive him, and he had to write her out of his will in case that did indeed occur. At a certain point, grandma’s dementia was so bad that she simply forgot to eat. My dad got a call from a physician in the NH asking to place a PEG tube. So of course, as the doctor in the family, I was consulted for my opinion. I felt that once she had a PEG tube, they would simply stop trying to feed her, and her last pleasure that she remembers on this planet, chocolate cake, would be gone forever.
So I did what any good doctor does: use a delay tactic. I asked for a swallowing study. They did one and she had no problems swallowing. There was no physical impediment.
So step two, I asked my dad to visit her with chocolate cake and see if she would eat it, and also investigate what kind of food she was refusing to eat. He discovered she was mistakenly being given a diabetic diet for the last few months, even though she was not a diabetic. She loved her sweets and that had been denied to her. Plus, she was like a 5 year old and veggies were not something she would eat voluntarily. Chocolate cake was not a problem, however. Given her age of 93, Grandma, as far as I was concerned, could eat whatever the heck she wanted. If she wanted to smoke and do drugs I would be OK with that too. I mean she was 93, healthy, and demented. What damage could be done at this point? I wanted her to have the best quality of life, and given my father’s investigations, I refused to allow a PEG tube.The physician at the NH was not pleased, but consented. The plan we worked out was that once a week my dad would bring a chocolate cake (for grandma and the other residents – making my dad quite a popular guy) and the NH would sprinkle protein powder on the cake for extra nutrition. At this point, grandma stopped losing weight, and one year later died in her sleep. She was not sent to the ER. No one pounded on her chest or stuck needles and tubes in her. She died peacefully and without pain. And her last meal was chocolate cake. If I had to go, this is how I would want it. And I truly believe that grandma is up in heaven somewhere thanking me for it. Sometimes modern medicine can prolong “life” with no attention paid to “quality of life.” Would a PEG tube have extended grandma’s life? Maybe. Would it have improved it? No. That is where I think we should focus our attention in respect with the growing elderly population. We need to acknowledge the implications of medical treatments and only do that which has a chance to benefit the quality, not just the quantity of life.–Ilene Brenner, MD

Pneumonia, the friend of the aged

Many years ago when I was an EP in Florida my grandfather resided in a nursing home. He’d had a great life first as a jeweler then as a retiree playing golf, swimming in the gulf, and spending time with his family.  But, because of dementia, at the age of 90, he had to be placed in a nursing home. It worsened to the point that he no longer recognized family but someone visited almost every day, helped him eat, and talked to him.  We loved him and we were glad to repay him for all he had done for us.

About a year after he had been there I received a call from my mom saying I needed to call my Grandfather’s doctor, which I did.  What I heard was that “he has a fever and pneumonia and has to go to the hospital.”  I said, No, he would be happier to stay in the nursing facility and die peacefully.  The well-meaning doc said that “OK, we will start antibiotics”.  I said that was not necessary, we want him to be comfortable.  I knew that is what my Grandfather would have wanted if he could tell us.  The doctor knew this was best and agreed.


This was 25 years ago but I remember that our family sat with my Grandfather around the clock for about 24 hours until he peacefully passed away.  I think it was Osler who called pneumonia the friend of the aged.  It rang true.  It takes extra time with families to ascertain what their loved one would really want which may often be peace.  When the situation presents itself I try and take the extra time to talk with family of patients that are elderly and demented.

On a number of occasions I have kept patients comfortable and let them die peacefully in the ED with family around, admitted them to the hospital with that understanding, or sent them back to a nursing facility with an order for prn morphine.  Once you go to that extra trouble to “tee it up,” the admitting hospitalist and nursing facilities are quite agreeable and the families have thanked me for helping them do what their loved one would want–a peaceful death with dignity.

–Alan Jon Smally, MD


My possible future self… 
When people think of geriatric emergency medicine topics, I suppose their eyes just gloss over, but not mine. I am an active 51-year-old and I compete in triathlons and half-marathon runs.  I certainly don’t believe in slowing down for needless reasons.  In the elderly, I often catch a glimpse of my possible future self. I see myself in the 85-year-old with urinary retention who can’t void and is horribly uncomfortable, and who needs a Foley catheter to accomplish urine flow, plus referral to a urologist to remedy his prostatic hypertrophy. I hope to live long enough to be placed in this situation! I see myself in the husband whose wife has had a stroke and who is receiving TPA. I try to dispel the fear in their eyes as I explain that part of stroke care is thrombolysis, but part is good stroke rehab care, so that the wife can possibly return to independent living, while I tell them that I am going to assemble an inpatient care team for her so that she has the best possible chance of an optimal outcome. I see myself as a future elder when I explain to younger family members that their elderly relative should not just “slow down and take it easy” as some sort of expectation of older age, and as I explain to them the general concept of physical de-conditioning and accelerated demise that is inevitable as a consequence of such misguided expectations. I believe “what goes around, comes around.”  By spreading kindness and knowledge to those who find themselves in a position in which I may some day find myself, I somehow increase the chance of good “Karma” that will one day come back to me. This is a part of the reason that I work hard to give a special kind touch to my elderly patients.
–Gary M. Gaddis, MD, PhD


Alan Jon Smally, MD is the Medical Director at Hartford Hospital, CT

Gary M. Gaddis, MD, PhD is a Missouri Endowed Chair for Emergency Medicine, St. Luke’s Hospital of Kansas City

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