Letter to the Editor: Death Is Not a Question of “If”

I read Dr. Gambert’s July 2012 column titled “Inoperable?—A Status Not Written in Stone” (www.clinicalgeriatrics.com/articles/Inoperable-Status-Not-Written-Stone) with great interest. I appreciate your awareness of the newest surgical interventions and thinking about applying them to people regardless of age. There is an area, however, that you did not bring up in your review of risks, benefits, and alternatives—death is not a choice of “if.” In our modern medical world, death is much more a choice about when, where, and how. This essential truth seems to escape us as physicians. An inevitable effect of coronary artery bypass graft surgery, pacemakers, implanted defibrillators, and other aggressive treatment is that many of us live long enough to live with and die from advanced dementia or live with other chronic conditions, such as significant daily pain from arthritis.

The 80-year-old woman described in your article developed delirium, a harbinger of dementia. Whether unresolved delirium leads to incident dementia or whether undetected cognitive impairments are worsened by the underlying medical conditions that cause the delirium leading to a new diagnosis of dementia, there is definitely a relationship between the two syndromes. Although I was not there to speak to the patient’s family, it sounds like they chose to honor her independence by not intervening, by letting nature take its course, and pursuing comfort measures for her in her final days. In today’s world, this seems like an unusual but perhaps thoughtful response.

I have seen far too many patients who tell me that they regret the medical choices they made in the past because they did not appreciate the difficulty of living with physical and cognitive disabilities. They did not anticipate that there would be any negative sequelae, and the medical professionals no longer involved in their lives did not forewarn them. These are not people suffering from major depressive disorder and inappropriate guilt, these are average men and women who anticipated getting older without deficits or difficulties and just dying in their sleep before developing chronic disease.

I disagree with you that her family chose to do nothing. The family chose to honor her independence and to let nature take its course. This is not nothing. This is a brave choice. This is a choice that some, though not all, would make if they were able to see into the future, if they were reminded that it is not if  we die, but when, where, and how.

Maureen C. Nash, MD, MS, FAPA

Chair, Clinical Practice Committee

American Association for Geriatric Psychiatry

Medical Director

Tuality Center for Geriatric Psychiatry

Hillsboro, OR

Dr. Nash reports no relevant financial relationships.