Clinical Geriatrics

We must not underestimate the importance of having someone available to advocate for an elderly individual’s “best interests.” While personal wishes must be honored, not all older people can express what they truly want done or not done (depending on their unique circumstances). “Living wills” can go a long way to clarify one’s prior wishes, but even here there may be room for interpretation.

Two distinct cases recently brought this issue close to me, each illustrating different aspects of the same issue.

Mrs. B is an 82-year-old widow who lived alone and remained independent, despite her requiring a walker to shop at local stores. Her activities were quite limited, though she enjoyed visits to her summer home in the mountains with her family and time spent with family and friends. Mrs. B had high blood pressure that was being treated with medication, and she had smoked for years. A “bleeding ulcer” led to her being hospitalized, and shortly thereafter it was noted that she had a cool, painful, and discolored leg. Evaluation revealed an arterial occlusion, and discussion soon centered around her need to have an amputation. Mrs. B was told that she would not walk again on her bad leg, and she was noted to be quite depressed. Although she expressed to her family her wish to do whatever was necessary to save her leg, including having arterial bypass surgery despite its own risks, her physicians felt that an amputation was the best solution. Mrs. B’s son-in-law, a physician, learned of this, and after reviewing the situation and examining her leg himself, discussed the options with other family members and advocated for her to have the bypass surgery when she was more stable. The amputation was refused at that time, as there was no urgent indication. The vascular surgeons said they would examine Mrs. B in a few weeks to re-evaluate. She was discharged to a nursing home and was wheelchair-bound, unable to walk due to leg pain. Numerous phone calls were made to vascular surgeons to discuss her options; finally, a vascular surgeon was found who was willing to perform the bypass surgery. Mrs. B was operated on, and after a few weeks the pain subsided and she was able to bear weight on her leg. It is now 1 year since the surgery, and she is walking independently up five flights of stairs. This weekend, she returned for a trip to her mountain home, something she has dreamed of all year and worked so hard in rehab to make a reality. Mrs. B was recently heard discussing with her granddaughter on a hot day the issue of wearing “stockings.” Despite the hot weather and apparent discomfort that the younger girl had expressed, Mrs. B said she enjoyed putting on her stockings every day, as it reminded her how lucky she was to have two legs to put them on, and how thankful she was to have someone who helped her avoid an amputation. Without someone advocating for Mrs. B, an amputation would have definitely been performed, and her life changed forever.

The second case involved an 82-year-old woman, Mrs. F, who became acutely short of breath and was taken to the local ER by a family member. A pulmonary embolus was diagnosed, anticoagulants started, and all seemed to be on track. The next day, however, Mrs. F became hypotensive due to unexpected bleeding from a venipuncture site that had not been contained appropriately, and became increasingly short of breath, thought to be due to an aspiration pneumonia; she was in need of ventilatory assistance. The family argued that Mrs. F’s “living will” prevented her from being on a ventilator, and that she did not want to have any “tubes to prolong her life.” The family said they were sorry they brought her to the hospital in the first place after giving thought to her “living will.” A family friend, who was a physician, was called. Careful review of the document demonstrated that Mrs.