Obama and the Elderly: Do As I Say ... (Updated)

"I'm a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he's the guy with the medical degree. So, if he tells me, 'You know what, you've got such-and-such and you need to take such-and-such,' I don't go around arguing with him."  -- President Barack Obama, May 3, 2009.

Obama goes on to speak, with genuine feeling, about his grandmother's decision to have hip replacement surgery after she was diagnosed with aggressive terminal cancer: she died two weeks after the surgery. Although he would have been "pretty upset" if someone told him she could not have the surgery, he questions whether an operation that will not prolong life is a "sustainable model" for medical care. The president proposes to seek guidance from a national "conversation that is guided by doctors, scientists, ethicists"  but is "not determinative."

He's right: we need to talk about end of life decisions. They are difficult, costly, and potentially destructive for surviving family members. Obama realizes that the bevy of experts he cites might have counseled against the operation. Should he have listened had doctors told him not to treat his grandmother or that a swift passing was best for her?

Surprisingly, this is the advice that many doctors currently give -- or suggest -- to families of patients suffering from so-called end-stage dementia, and they are backed by hospital "palliative care" units and "ethicists." These latter say they want to help families make their own decisions, but health care practitioners have an agenda that they pursue aggressively: the speedy demise of the severely demented.

Hospitals deny that they are practicing or urging euthanasia. I think they are.

The most well-known cause of dementia, Alzheimer's disease, has been diagnosed in some 4.5 million Americans, and perhaps as many more suffer from other causes of dementia. Exact numbers are hard to come by because death certificates often list only resulting complications. Dementia is a progressive deterioration of mental functioning. In its advanced stages, the centers of the brain that control appetite cease to function; patients lose their desire to eat and, eventually, their capacity to swallow. Untreated, they starve to death. A decade ago, physicians commonly installed feeding tubes in these patients, and a large study showed that patients could survive from one to three years with this procedure.

End-of-life health care is costly, and several recent small studies have seemed to show, against common sense, that patients with feeding tubes do not survive longer than those who do not receive them. When pressed, physicians acknowledge that these small studies are inconclusive, but they nevertheless embrace them. It is hard to imagine another case where inconclusive results in a handful of small studies challenging long-standing practice in a life and death situation would trump practice. When it comes to the elderly, though, the medical profession seems to have a different set of rules. So it is that physicians now counsel families not to treat the severely demented.

Death by starvation appears to be as gruesome for the patients to endure as for their families to witness. However, medical professionals insist, without evidence, that the demented cannot feel pain. It is a cruel irony that these same patients, supposed so demented as not to suffer pain, are credited with choosing not to eat. Medical professionals give patients a swallow test: they put some ice in the back of the patient's throat. Patients who swallow the ice are declared to be capable of swallowing: they are, therefore, choosing not to eat. It is as if doctors would test the muscles in a stroke victim's arm, find them intact, and declare that he had chosen not to use the arm. The argument is used to mollify families. Doctors recognize the desire not to eat as a symptom of dementia.