DRHOOK- Goodbye, granny: Tell your doc your end-of-life plans

the handsome doctor John Hong of Charlottesville

"Grandma Got Run Over by a Reindeer" is an interesting song. Maybe opponents of End of Life (EOL) counseling should use that melody for "Pull the plug on my dear old grandma." Hmm, something tells me no one will be singing that song during Christmas. 

And I don't think Rudolph would intentionally run over grandma– but what if grandma were run over by a reindeer?

EOL issues are as fun to discuss as asking your parents if they ever had an affair– or if you are a product of that affair– or if dad cross-dressesd– well, you get the point. 

In the past, doctors took a paternalistic role in EOL issues. However, in the past 25 years, patients and/or their surrogates now are involved in these decisions. But let me ask, have you ever discussed with your doctor what medical care you would want should you be close to the end?

Considering half of folks over the age of 85 have dementia and many senior citizens become delirious with an acute illness, shouldn't medical professionals and family know ahead of time what grandma or grandpa would want?

When I was a medical resident in Los Angeles, we were required to ask all admitted patients if they had advance directives. The folks who were young would stare at us and say, "Does that mean I'm going to die?" 

We'd explain that we were required to ask everyone in case something "unexpected" happened. It gave us a chance to understand the patients' goals and values (religion, views of quality of life, thoughts about independence and control, personal relationships, etc.). 

However, in the outpatient setting, discussing EOL issues is really difficult. The main reason is time constraints. During a 15-minute office visit, addressing emphysema, heart disease, and diabetes takes precedence over, "By the way, can you tell me what your goals are over the next five years?" 

A doc needs to have dinner with every patient to go over issues like this. 

"Pass the peas, please, and if you couldn't voluntarily eat anymore, would you want us to puree those peas and feed them into your stomach with a tube?"

Studies have shown that advance care planning improves doctor-patient/surrogate communication as well as enhances quality of end-of-life care. 

Look at hospice care. Studies show it actually prolongs not only the quality of life towards the end, but also prolongs the longevity to some degree– perhaps because the person has less pain and suffering. 

I've seen some family members become really, really, really mean when they disagree with other family members about mom or dad's EOL care. If a surrogate isn't chosen (a proxy who has medical power of attorney), there can be a clash of the titans (especially if a large inheritance is involved). 

Also, even with a living will or a more specific Instructional Directive that spells out what kind of medical care the person wants should there be a poor prognosis, family members can waver about what should be done. It is hard to let a family member go, even if the person is suffering. 

So it's good for the doctor to know the patient's wishes to help guide the family in the direction of what mom or dad wanted.

Is an EOL meeting with your doctor so bad? Is it "pulling the plug on grandma" or doing what grandma would want– which includes keeping the plug in the socket?

For more information and forms on health care proxy and living wills: caringinfo.org 


Dr. Hook cracks a joke or two, but he's a renowned physician with a local practice and an interesting website, drjohnhong.com. Email him with your questions.