Some Nursing Home Elderly Get Futile Care

New Research Emphasizes Need for Doctors, Families to Consider End-of-Life Care

(AP)  A surprising number of frail, elderly Americans in nursing homes are suffering from futile care at the end of their lives, two new federally funded studies reveal.

One found that putting nursing home residents with failing kidneys on dialysis didn't improve their quality of life and may even push them into further decline. The other showed many with advanced dementia will die within six months and perhaps should have hospice care instead of aggressive treatment.

Medical experts say the new research emphasizes the need for doctors, caregivers and families to consider making the feeble elderly who are near death comfortable rather than treating them as if a cure were possible - more like the palliative care given to terminally ill cancer patients.

"We probably need to be offering a palliative care option to many more patients to make the last days of their lives as comfortable as possible," said Dr. Mark Zeidel of the Beth Israel Deaconess Medical Center in Boston, who was not involved in the studies.

Palliative care focuses on managing symptoms of a disease and a main goal is to relieve pain at the end of life.

End-of-life care became a divisive issue in the national health care reform debate this summer after one proposal included Medicare reimbursement for doctors who consult with patients on end-of-life counseling. Critics called the counseling "death panels" and a step toward euthanasia. The Obama administration denied those claims, yet has signaled the Medicare benefit will be dropped.

The new studies are published in Thursday's New England Journal of Medicine.

In one study, doctors looked at health records of 3,702 nursing home residents nationwide who started dialysis between 1998 and 2000. The average age was 73 and many had other health problems, including diabetes, heart disease and cancer.

Within the first year, 58 percent died and another 29 percent declined in their ability to do simple tasks such as walking, bathing and getting dressed.

Kidney dialysis helps remove waste from blood, and the vast majority of patients with kidney failure benefit. However, in the case of seniors with failing kidneys, it is less clear whether the benefit outweighs the burden.

The findings call into question the common practice of transporting dialysis patients near the end of life to dialysis centers several times a week and hooking them up to a machine for hours at a time.

"We may be overestimating the benefits of dialysis in some of these patients and downplaying the burdens," said lead author Dr. Manjula Kurella Tamura, a Stanford University kidney specialist.

The study did not include a comparison group of patients who didn't get dialysis, so it's unknown if more elderly are dying after starting dialysis than not. Kurella Tamura said there's no one-size-fits-all recommendation for which nursing home residents should go on dialysis, and she suggests patients talk with their doctors about realistic expectations.

The second study followed 323 people with advanced dementia from Boston-area nursing homes. Their average age was 85 and they could not recognize loved ones and were unable to talk or walk.

One out of four died within six months and half died during the 18 months they were followed. Nursing home residents with advanced dementia were more likely to die of pneumonia, fever and eating problems related to their dementia than from strokes or heart attacks.

During their final three months, 41 percent received aggressive care including being hospitalized and tube feeding. However, if the person making their medical decisions was aware of their poor prognosis, they were less likely to receive aggressive care near the end of life, the research found.

"We often temporarily inflict discomfort or pain on patients. We try to minimize it, but we accept it because we think the trade-off is curing or healing," said Dr. Greg Sachs of Indiana University School of Medicine.

In an accompanying editorial, Sachs recalled how his grandmother, who suffered from Alzheimer's and lived in a nursing home, was aggressively treated with antibiotics for every infection in her final months and had to be restrained. He said that people with dementia could benefit from hospice care inside a nursing home or in the community.

Sachs cited research that found nursing home residents who had hospice care during the last month of their life were half as likely to be hospitalized. What's keeping dementia nursing home patients from getting hospice care is that dementia is not widely recognized as a terminal illness. It's also harder to predict when a dementia patient has six months or less to live - a criteria for Medicare-paid hospice care.

The National Institutes of Health funded the studies. The dementia study was led by the Harvard-affiliated Hebrew Senior Life Institute for Aging Research in Boston. In the dialysis study, Kurella Tamura has received grant support from Amgen, which makes a drug for people with kidney disease undergoing dialysis.

[molliemushka]

I have lived the pain of the greed of a medical doctor who exploited my demented husband in favor of hooking him up to dialysis which generated lots of money to the doc. It did not matter that I had a full legal Healthcare Power of attorney to be my husband's advocate
Folks dialysis is torture of the worst kind. My husband hated it but this doc kept declaring my husband competent contrary to the opinion of three psychiatric exams. The IG found that my husband's rights were violated. The story gets even worse. After withdrawing dialysis
my husband's kidneys dramtically improved. So he did not have End Stage Renal disease which would have been clear to this doc had he even checked with me the POA as instructed to get a good medical history or even checked my husbands records. It is very possible this doc was covering up hospital acquired renal failure while making a mint doing it. He had the exclusive contract with the hospital for dialysis and his own dialysis center which make over 2 million a year.
The debate is about pulling the plug on grandma is not about grandma at all. It is about a medical community that wants the govt to subsidize them directly and wants no one interfering with the decisions or treatment choices they make for their patients. You see their income depends on how much and how often they treat the patient wheter the patients needs it or wants it. Let's face it folks some medical folks would keep grandma plugged in so they could hear the Ka
ching, ka ching all the way to the back as long as they can keep a pulse. They care nothing about quality of life or the patient. Stay tuned folks. Medicare is taking this serously and I will continue my advocacy for those with memory impairments that can fall prey to medical abuse.

[sjc_1]

Health care is one big gravy train for some. You hear stories about nursing homes from time to time over the years, but it never seems to get much better.

We should all be judged by how we treat one another. It is an indication of who we are as a people and as a society when we look at how we treat the sick and the elderly. The right wing calls if "bleeding heart liberalism" to care. You are not going to do good with THEIR money, when they have taken that money by cheating and exploiting others.

[misands]

jimmyc1955 -

Do you really think insurance companies don't already have the very sort of 'death panels' you people on the right rattle on about if we get national healthcare? If you don't, then you live in a fool's paradise. At least anything the government creates ultimetly must address the possible wrath of the voters, whereas the insurance companies that make these life and death policies do so behind closed doors with no threat of voter backlash.
Once I know I'm at the end of my life (which is inevitable for us all), I don't care to selfishly use up resources that would be better spent on people who still aren't at then end of their lives just to extend my life by a few months. Some of us don't plan to pass into death kicking, screaming and fighting all the way.

[jimmyc1955]

misands -

Did you read the article?? Did it not catch your attention that families were capable of continuing care at their choosing? That insurance companies are continuing to pay? I have had very personal experience with this - a friend was in a car accident - went into a coma - continued to receive around the clock care for 3 years - until they quietly died. The family had a CHOICE - you seem to want to take that choice away.

What you choose is certainly your business, but to project what you believe (and it will change in time - I am sure) do you really feel that a government agency will have your welfare in mind? If I choose to continue care - or the care of a loved on - past when the "experts" decide the "quality of life" isn't up to their standards - I have no say anymore?

You would be the first to scream about anti-abortionist trying to impose their chosen life/death beliefs on others - but you have no problem imposing YOUR chosen matters of faith on me.

Don't you find that a bit hypocritical?

[rocketjl]

"In one study, doctors looked at health records of 3,702 nursing home residents nationwide who started dialysis between 1998 and 2000. The average age was 73 and many had other health problems, including diabetes, heart disease and cancer." This really sounds like a crock. It is even harder to find one doctor who will really read his own patients records, much less all patients from 3 thousand nursing homes. Don't tell me that Obama's boys put this out to help us think about putting death panels back in the health reform stuff????

[ChaplainT]

The truly amazing aspect of this discussion is just how many people who claim to be enlightened "truth seekers" are absolutely unwilling to accept that while we are on this earth, we are Spiritual Beings having a Physical Experience, and, each of us will encounter Physical Death as our "Final Act of Living" on this earth! As a Chaplain who has been present at more physical deaths than I can count, and a Father, who has been present for the birth of several children and grandchildren, these two experiences CAN be deeply Spiritual and meaningful, OR, they can become horrible, painful, and shocking...& much of the outcome is dependent on how we prepare and react to the reality of each. I must say that, in my personal experience, (and I've been informed by other health professionals that their experience is similar), when an individual and his or her family have availed themselves of the Hospice Benefit for the last few months of their Physical life, and have properly prepared to accept the eventuality that "it will be their time to go" at some point, the process of dying, AND the moment of death is typically less difficult for all parties concerned than the unfortunate "Patients" whose Physicians perpetuate the illusion that "Physical life can be extended indefinitely..." encounter. To gain a bit of understanding, one needs only to consider the phrase "Do Not Resuscitate". While there is no doubt that in the case of younger, basically healthy individuals who has been in an accident, etc. "Resuscitation" can be a good and helpful procedure; however, in the case of those of us who are frail, elderly, ill, etc., it can be a cruel procedure-one in which an inordinate amount of (unnecessary) pain is inflicted without good cause, and OFTEN against the wishes of the individual who is enduring the pain! Think of the semantics of "DO NOT RESUSCITATE"...as I've explained to both my loved ones and many individuals and families struggling with the decision.."DO NOT RESUSCITATE..LITERALLY MEANS, 'DON'T PRETEND I'M ALIVE AFTER I'VE DIED!'" By accepting the reality that Death IS in each human's future, one is not embracing Death as something we wish to rush toward, but rather is accepting a thing that we humans cannot change--and in many cases, can be much more humane and loving than is the case when, whether at the behest of a well intentioned family member or medical professional, the frail, pain filled body of an individual is practically "exhumed" for the sake of performing a procedure, whether it be dialysis, chemotherapy, radiation, or surgery. As is the case in many areas of our lives, WE often exacerbate the PAIN associated with dying, by failing to accept it's inevitability, and attempting to change or control that over which we have no control. The end result of the futility of trying to control that over which we have no control is that WE become more OUT OF CONTROL! And it is no small reality that, for people of faith, death of our physical life can be "swallowed up in the victory of our Spiritual Journey". To accept reality is NOT synonymous with wishing for or causing unpleasant things to happen--the acceptance can simply help us become better rather than bitter!

[jimmyc1955]

Wow - not one comment. That is the most amazing aspect to this article. Does nobody else find it alarming that we are starting to talk about how people should die to help us all save money? Isn't that, in effect, the bottom line of this article?

Frankly I find the phrase "quality of life" a little too much like eugenics. We all just "know" that that is. Of course once we have nationalized health care we will have a panel of "concerned experts" who will be judging what peoples proper "quality of life" is - and when they don't need "aggressive care" anymore.

With all these spongy feel good phrases we are missing the point that we are turning over our most basic God given right - to life - to a government panel who will over rule our wills, our rights and our families wishes.

[rocketjl]

And so CBS, Congress and the White House still claim there is no such thing as 'death panels'. I am 71 years old and I have a recommendation as to what all those clowns in the Washington D.C. acting theater can do with their panels. They can implement panels for themselves, god I wish they would, but leave the rest of America alone.