Cause of Death
Probably like a lot of readers here, I grew up watching Norman Lear sitcoms, the greatest of which, “All In the Family,” when it was funny, there was nothing funnier on. “The Jeffersons,”, “Good Times,” “Sanford and Son” … there were a lot of laughs from those legendary shows.
And I was sad to see that Lear had died, but not surprised. He had publicly sported that iconic canvas hat and wry grin for more than five of my six-plus decades. Then I saw a news blurb that Lear’s “cause of death has been determined.” Apparently, the medical examiner determined that he died of cardio-pulmonary arrest, with a contributing condition of congestive heart failure. Norman Lear was 101.
Which reminds me of a story. Years ago, my mom called me to let me know that my aunt had gotten my grandmother out of the hospital, where she had been admitted for anemia. After a couple of units of PRBCs, Grandmama felt in the pink, and so my aunt checked her out and took her to lunch. Cool, I said to my mom, glad she’s better.
Concerned, my mom asked, “What could have caused her anemia?” I told my mom that off the top of my head, I could probably think of about twenty different things that might cause anemia in an elderly lady, but then followed up with, “Who cares?” My grandmother was 100. Were we going to inflict a colonoscopy on a 100-year-old, and what would we do about any abnormal findings? Were we going to involve a hematologist and try to run down a myeloproliferative disorder, and maybe contemplate bone marrow studies? My mom got it, and I followed up with, “The proper treatment for a 100-year-old-lady with anemia is give her some blood, and take her out to lunch.” Grandmama made it another comfortable two years, and we enjoyed a number of happy lunches more before she passed.
We do more for people in advanced years now than we used to, and sometimes that’s the right call. I know a very respected, old-school surgeon who has done appendectomies on a couple different patients in their late nineties, both of whom did wonderfully and resumed a good quality of life. Sometimes a little peak or tweak with a med here or there helps the very elderly. I’m not at all suggesting that we don’t consider and recommend appropriate interventions on an individual basis.
I am saying that too many people, including in our line of work, discount Father Time as the cause of death. Whatever individual parts or organ systems fail from simple wear & tear, it’s not wrong, nor inaccurate to recognize that often, someone like Norman Lear simply got old and died, and it’s okay to leave it at that.
As a patient, I’ve had several talks with new doctors (I avoid NPs and PAs except as an emergency or VERY routine things), asking if my grandparents are still alive. No, they’re not. Two of heart attacks, one of Alzheimers. The third grandparent died in a mishap. Since I was in my 30s, they’ll jump all over that, offering all manner of tests, tablets and “lifestyle changes”. Ummm, did I mention that all except the accident victim were in their 90s when they died? Doesn’t everyone eventually die of something?
A golden opportunity to use “ the dwindles” as a cause of death. Time to make up a cpt code.
Defining futility and accepting that further efforts are futile, and that often in advanced age the attempted cure is worse than a welcome quick death is a tough sell. Too many anecdotes to mention, but we all have them.
Amen. I recall the 100 year old sent to me by a FP who I had a long relationship with, for a 1cm BCC on the arm. I called him and asked if he really meant to send her over. He was horrified, and said absolutely not. Of course, it was his new NP. Sometimes, you just don’t mess with the 1923 models, no matter how good they look!
A second comment. There is a study a few years ago that showed that elderly physicians used far fewer medical dollars in their last years of life than the general population. We understand how futile some things are as well as there is a cost both with time, side effects as well as financial for these treatments..
My favorite story is the patient who was 82 with severe congestive heart failure and could not get out of a wheelchair. He was diagnosed with an advanced melanoma. The life expectancy of his CHF was about 6 months. The chemotherapy at the time had a 10% chance of giving him an extra 3 to 6 months at a cost of $80,000 and a lot of appointments and side effects. I tried to discuss the options but it was the family that was hell-bent on having him have everything done. I sometimes think though that if people had to pay out of their own pocket, instead of other people’s money the decisions would be different.
In reality that $80,000 is 2 years salary for a 20-year-old. Can you imagine going to your 20-year-old self and telling them you need to work for 2 years for free so that when you’re 82 and ill you can live three more months. I bet 99% of people would say that’s insane. Yet that’s what we’re doing as a society.
The far left feels that money does not matter and everyone should have everything. The far right quite often feels that for religious reasons everything should be done. This is probably the only time these two sides agree and push for the extraordinary care. Doctors don’t want to be sued and follow the families wishes. The families don’t care because they don’t really understand the negatives and they don’t have to pay for it.
Pat, you are spot on. A physician here in my hometown routinely takes the all hands on deck approach when dealing with any obvious late stage terminal illness or advanced elderly. I have always taken the stance that we should treat people within the realm of reason. If treatment is not reasonable, then comfort care comes in to play. I had to stop them from coding my father. He had advanced heart and lung disease, had a living will, and was in a nursing home. He arrested so my sister immediately panicked and told them to go all out. I walked in to the ER with a full code going on and told them to stop. Sometimes less is better.
Pat, just as an aside and apropos of nothing, Lear was a hero in WW2. B-17 crew. Gunner and radioman. Flew FIFTY TWO missions and survived. My God, what a man…
That’s amazing.