Book Review

Growing Old Gracefully

Choosing Medical Care in Old Age: What Kind, How Much, When to Stop

N Engl J Med 1994; 331:485August 18, 1994

Article

Choosing Medical Care in Old Age: What Kind, How Much, When to Stop
By Muriel R. Gillick. 208 pp. Cambridge, Mass., Harvard University Press, 1994. $19.95. ISBN: 0-674-128-125

Dr. Gillick, a clinical geriatrician, uses the stories of her own family and her patients to explore the controversies surrounding medical care in old age. She considers the unique circumstances of four kinds of patients: the demented, the robust, the dying, and the frail. She asks difficult questions about patients with dementia. Is a point ever reached when vigorous medical treatment no longer makes sense because it turns to torment? Gillick considers the problem of aggressive treatment for a woman with advanced dementia; such treatment was demanded by her family but felt to be contrary to her best interests by her professional caretakers. The author proposes the development of standards of care that avoid the most intrusive measures, choosing a middle ground in which the benefits of treatment are weighed against its hazards and discomforts.

Gillick does not reject aggressive care for the robust elderly. Age alone is a poor criterion for rationing health care, particularly when the goal is to maintain function. For example, pacemaker placement, abdominal surgery, and dialysis benefited her healthy but very elderly patients. Objections to aggressive treatment are based on limited life expectancy, but an 85-year-old man can expect to live another six years. Is this not a meaningful length of time when one considers the quality of his life? Another argument is expense, but the costs without treatment may also be high -- for example, a pacemaker weighed against a hip fracture in a patient with complete heart block. Physicians must be able to assess accurately the robustness of their patients and tailor treatment to individual capacity.

Medical care cannot alter the fact of death, but it can influence the quality of the patient's life until death and the manner of death. A serious difficulty is knowing when the dying process has begun. Consider the previously robust elderly person with a small stroke, then pneumonia, multisystem failure, and death in the intensive care unit on a respirator. When along this patient's downward course did it become clear that she was dying, that further intensive care was futile? Negotiating a treatment plan with specific goals within a time limit may be reasonable, but Gillick acknowledges that many patients and their families struggle with the decision to abandon hope even when a good outcome is doubtful.

It is easy to understand this attitude after considering the lives of the frail elderly. Multiple medical and functional problems adding up over time make conventional treatment both potentially lifesaving and life-threatening. What should have been done for the patient who endured one crisis after another, surviving each but recovering to a less capable, more debilitated state until death occurred? Gillick points out that patients are well informed about the risks and benefits of a specific procedure without fully understanding the possibility of a “nightmarish cascade of catastrophes.”

Stopping aggressive treatments for the frail elderly remains controversial. They are not terminally ill, but as the quality of life deteriorates, it becomes increasingly unlikely that interventions will produce the hoped-for results. There may come a point when traditional medical care becomes burdensome to the patient and the best interest of the patient lies in personal care aimed at ensuring comfort and dignity. But the challenge is not just medical; it is also social. Functional limitations make elderly patients increasingly dependent on others and paradoxically isolated socially. Finding the right nonmedical long-term care may be more important to a patient's state of health than all the available advanced medical technology.

Behind these common-sense proposals is Gillick's belief that they are reasonable because they are humane and are based not only on the patient's state before illness and the physiology of disease, but also on an understanding of what the treatment entails. If patients and families could understand the nature of illness, they too would find these goals reasonable. She contends that as a society we must reach a consensus on reasonable care for the elderly. Clear and unambiguous standards will guide patients, family members, and physicians in medical decision making.

How to achieve this social consensus through the sharing of experiences of illness, and not regulatory mandate, is problematic. Its implementation will require substantial institutional changes. Nursing homes must become a valued rather than feared choice. Hospitals must provide better, less disruptive care for elderly people that focuses on maintaining function rather than promoting regression. We should revitalize the old concept of an infirmary for elders without the complex technology of tertiary care. Insurance reform will be necessary. Acute intensive care is currently rewarded; supportive, palliative comfort care is poorly reimbursed. Expansion of hospice and home-care benefits is essential.

Physicians' behavior must also change. Regulations, legal questions, quality standards, and medical training make physicians apprehensive about limiting care. Goals are not clearly set with patients and family members, who fear that the limitation of treatment means something is being denied. Realistic information about the medical conditions, treatment options, and probable outcomes in Gillick's four patient groups must be developed. If these extensive institutional and attitudinal changes occur, Gillick believes a just, rational, and decent approach to illness near the end of life can be achieved.

Gillick's personal and compassionate approach to medical decision making in old age is bound to spark controversy about patients' autonomy, proxy rights, rationing, and standards of care. Her ideas about institutional change strike at the structure and process of today's health care delivery system. I hope this book, with its accessible style, will be widely read, not only by clinicians but also by ethicists, policy makers, and the general public and that it will stimulate the conversations that will ultimately lead to the social consensus Gillick feels is missing today when we choose medical care in old age.

Katherine A. Hesse, M.D., M.S.W.
New England Deaconess Hospital, Boston, MA 02215