Suicide among the Elderly

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In terms of cost savings, suicide among the elderly would be quite effective. Perhaps “suicide panels” would be as successful as the imaginary ”death panels” that caused so much consternation as healthcare reform was being processed. A ready-made theme song for “suicide panels” could be “Suicide is Painless“, the theme song from the hit TV show, Mash.

As ghoulish as this sounds, this is not a one-time Halloween trick. Indeed, something like this was even predicted by the outstanding pioneer in studying suicide, the psychiatrist Herbert Hendin, M.D. In his classic book, Suicide in America, Hendin discussed the unique challenges of suicide in the elderly. He pointed out that the history of large birth cohorts, like we have had with the “baby boomers”, usually manifests with increased stress through life and correspondingly higher suicide rates at every age level. When the stressors of aging are added on, the suicide rate will predictably be even higher.

The rate of known suicide is highest today in the Caucasian male elderly, rivaled only by adolescents. For these men, the particular stress is often the loss of status and authority that has given their lives meaning. For all elderly, among other increased risk factors are prior suicide attempts, severe depression, dual disorders of substance abuse and/or anxiety, antidepressant and/or anticholinergic medication exposure, prior Electroconvulsive Therapy, vascular disease, and beginning dementia. New research suggests that these factors can cause alterations to reward systems in the brain, increasing vulnerability for impulsive suicides.

Given these factors, it may not be surprising that the success of suicide attempts also increases in the elderly. While the overall known ratio of attempted suicides to actual suicides is about 10 attempts for every completed suicide, among the elderly suicide attempts and completed suicides are estimated to occur at the same rate. A typical sequence is a non-serious attempt followed in a relatively short time by a potentially lethal attempt, often by a gun.

Dr. Hendin took a strong stand against so-called physician-assisted suicide and euthanasia, sensing that these could be used against those viewed as a burden to society, such as the elderly. He was especially concerned about euthanasia for psychiatric patients who are suicidal, given the distorting influence of the depression that is almost invariably concomitant in the suicidal elderly.

These subtle, and not so subtle, pressures toward suicide have confronted me more than once in my career, even though I was not a geriatric psychiatrist. I recall when I was Director of our not-for-profit managed behavioral healthcare system, as described in my book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (1997), that when we had high cost, treatment resistant, suicidally depressed patients, our administrator more than once exasperatedly exclaimed: “Just withdraw support, it’s hopeless, and we’ll overspend our capitation with more of these”. Dr. Hendin has also described similar scenarios in non managed care situations.

I was more recently reminded of how suicide is viewed differently in the elderly when I was part of a panel on suicide on Yom Kippur, the Jewish High Holy Day when most religious Jews pray to be put into the “Book of Life”. I presented for the first time publicly a patient who had died by suicide under my care during the initial stage of my psychiatric training. He was an elderly man who had lost his job and was in a loveless marriage. In his second session, he seemed a bit better. Later, I was to learn to be wary of this brief time of looking better, as the patient may have the energy to now decide and plan a suicide. The next week he walked into Lake Michigan and drowned.

As I began to speak, I sobbed instead, only to be comforted by the father of a teenager who recently died by suicide. Nevertheless, the lively discussion that followed was all about preventing suicide in the young, not at all about the elderly.

Yet, there is much that we can probably do to prevent suicide in the elderly, if we value that stage of life enough to give the attention and to spend the resources. Akin to those who survive suicide attempts at any stage of life, people often decide they want to live, especially if helpful treatment is provided to relieve the frequent unbearable psychological and/or physical pain.

Primary care physicians, in particular, have an opportunity to intervene, as they often have seen patients within the prior month before a suicide. The elderly grew up at a time when mental illness was even more stigmatized than today, so that they don’t readily admit to depression or ask for help. These doctors can also be on the lookout for the more passive suicidal behavior. Self-starvation, poor medication compliance, and frequent accidents can be a mask for a slow suicidal process.

Community services can reduce the risk. More and better community supports are necessary replacements for important losses. Perhaps even the robots that Jim Sabin discussed in his recent post on Grandma and Her Robot, will help when humans aren’t sufficiently available.

All this is not to say that some suicides in the elderly could be concluded to be rational ones and therefore not be prevented. However, we should do everything in our power to make sure that they are not irrational suicides that could be prevented. Otherwise, we will be allowing de facto suicide panels, will we not?

H. Steve Moffic, M.D., 67, retired from clinical practice at 65. He was fondly deemed a “psychiatric gadfly” by the Chair of the Department of Psychiatry where he first trained. His book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare, published in 1997, was the first extended discussion of the ethics of managed mental health care.

35 Responses to “Suicide among the Elderly”

  1. Ted Marmor

    thanks for the thoughtful commentary. This is a topic about which I do not have developed thoughts, but appreciate the blog precisely for stimulating reflection on such topics.

    Reply
  2. Ted Marmor

    Dear Jim, Your post, which has prompted interesting commentary about ageism and medical treatment, had a different impact on me. I kept thinking of the difference among age revelation as threatening and the concerns about the effects of retirement on well-being. When asked about where I “teach,” I say I am retired and then typically explain that I am on a lifetime research grant called TIAA-CREF. The not-so-hidden motive is to alert others to my still being engaged professionally. That concern, I think, can happen to those who retire “early” and is sharply separate from the social meaning of revealing one’s age, important as that is.

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  3. Steve Moffic

    I’m pleased, Ted, (if I can call you that) that you liked the blog, especially since it was an unfamiliar topic. Moreover, I am assuming from that that you have not had suicidal thoughts over 65, which is also welcome to hear.

    Steve

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  4. Jim Sabin

    Hi Ted & Steve -

    Ted – I’m not sure if you intended your second comment to attach to the post on “Suicide in the Elderly” or to the earlier post on “Coming Out About Age.” I like your definition of TIAA-CREF as a lifetime research grant, and will probably say the same as soon as I’m supporting myself that way. (I’m currently employed on a half-time basis.) And your distinction between the status of “not working” and the status of “old” as separate, (though often related), is valuable.

    Steve – my uncertainty about whether Ted’s comment connects to your post on suicide points to a question I was going to ask you – namely, how you interpret the idea of “rational” suicide among the elderly. In my clinical practice I was occasionally asked to consult about the care of patients who were choosing to opt out of life sustaining treatment. When their choice clearly reflected longstanding values and did not appear to arise from confusion, anger, feelings of abandonment, or other potentially “treatable” causes, I regarded the choice to bring about death as “rational.” Supporters of physician assisted suicide argue that having that alternative can relieve patients (who meet the criteria Oregon and Washington have set for “eligibility”) of doing something violent and furtive like using a gun.

    Thanks to Ted for his comments and to Steve for the thoughtful post.

    Best

    Jim

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  5. John Hardwig

    I wish Dr. Moffic had started where he ends: there are undoubtedly rational suicides among the elderly. In the elderly, what percentage of suicides or suicide attempts are rational? Can we safely assume — or is there good evidence — that only a very tiny percentage of suicide attempts by the elderly are rational? Isn’t suicide – and thus also suicide prevention – a very different thing in the elderly than it is in the young? (An old person, after all, has already lived her/his life; a younger person is “just starting out” or in mid-course, and may go on to a wonderful future.) And even deeper, what makes a suicide rational or irrational in the first place? After all, if you can really make your peace with it, isn’t suicide a very good death, much better than the elderly person might otherwise expect? Could some suicides even of people with mental illnesses that have proven resistant to treatment be perfectly rational?

    Don’t we need to start with those questions? After all, there are also dangers in pathologizing suicide to too great an extent. Perfectly rational suicides get too quickly classified as irrational and attempts are made to prevent them. To the extent that healthcare professionals learn to be on a suicide alert with elderly patients, those of us nearing the end of our lives and believing that suicide would be a very good death for us (and often, our families, too) will need to steer clear of contact, not only with healthcare institutions (in which suicide prevention is routine), but also to stay away from our doctors. Can that be the prescription for a good death?

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  6. Steve Moffic

    Thank you, Dr. Sabin and Mr. Hardwig for your reflections on rational suicide. I must admit I focused on the other kind since I am a physician who tends to look for illnesses that can be treated, and also because the topic deserves a separate blog. I would say that I do believe in physician-assisted suicides if carefully considered.

    I don’t know, nor do I think anyone knows, what percentage of suicides, or better yet termed, death by suicide, could be concluded to be rational. I agree that is likely to be more common in the elderly.

    I would include some of the following into what might be “rational”. Rational is not the opposite of mental illness. To me, as Mr. Hardwig suggests, unremitting, painful severe mental illness might qualify. Certainly, those with severe illness, with no concerned love ones, and who have unremitting physical and/or psychological pain despite good treatment might qualify. Then there are culturally sanctioned suicides like kamikazes pilots and Tibetan monks in China. However, when the intent is homicidal, as in kamikaze pilots and suicide bombers nowadays, perhaps homicide is the more appropriate terminology.

    I just would not want a chance that someone who could be helped to lead a happier and meaningful life at any age to allow us to be too cavalier about rational suicide. I just viewed the Veterans Day parade in New York, and on the surface, so many of the severely injured wounded warriors lead such difficult lives. Many made serious suicide attempts earlier, only to live and be thankful later that they did, like so many of my patents. So many succeeded in dying by suicide, devastating families and their fellow soldiers. Of course, limiting wars and having adequate resources to help could prevent many of these.

    Well, enough for now. This almost is another blog.

    Dr. Moffic

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  7. Paul Joseph

    These have been very wise comments overall. As someone who falls into the “danger set” (69 y.o. white male, retired professional, financial uncertainty, four prior suicide attempts and hospitalizations) I can concur that the inner view of suicide contemplation does indeed change over the course of a lifetime. All my previous experiences were impulsive acts provoked by a crisis in a personal relationship, following a prolonged period of agitated depression. The previous actions were all before the advent of modern antidepressants, though I was in psychotherapy at those times. I am currently receiving medication and weekly talk therapy. But the thought keeps pestering me that I am probably too old to change my fundamental outlook on life and that eventually the depression will catch-up with me again, and I will not make my previous mistakes in method. I do have a gun now. It is my safety cushion. It provides me with the confidence that I will have a way to solve the problem when the depression again proves too much for my therapist and me to master and control. After more than fifty years of such visitations, it would be unreasonable for me to think that it will not return yet again. I have already decided that I cannot and will not force myself to endure another bout of the terror, anger, and grief that characterize my condition at its worst. Having this history and the amount of forethought that keeps me company these days, does it qualify for a “rational suicide”?

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    • Steve Moffic

      Thank so much, Mr. Joseph, for sharing your poignant experience and thoughts, and trust you have also shared all of them with your therapist.

      Not being your therapist, I can only respond in generalities and principles. I think a case could be made for more optimism than pessimism. Why? Seems like you have some idea of what the trigger can be for depression worsening, so that might be prevented or reframed. Moreover, you suggest a long time since the last severe episode, suggesting the development of more insight and/or resilience, let alone the help of staying on the newer antidepressants. You’ve also found some thoughts and plans that provide some psychological reassurances for living rather than dying. Second, aging offers the opportunity to reminisce and put more meaning into one’s life, even a very painful life. Then, of course, more effectve trearments can emerge over time. Time, therefore, may be more on your side, and on the side of others like yourself, than against it.

      Dr. Moffic

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  8. Faye Girsh

    Assisted dying in cases of completed life (old age rational suicide) and for people with severe chronic mental illness are available now in the Netherlands, Switzerland and Belgium. These issues will be discussed at the 21st Conference of the World Federation of Right to Die Societies next Sept in Chicago. See http://www.WFConf2014.com.

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    • Steve Moffic

      Thank you for that information and opportunity to learn and hear more about this critical subject.

      Dr. Moffic

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  9. Carol Eblen

    When we talk about the elderly and assisted suicide, aren’t we talking primarily about Medicare/Medicaid patients and public policy concerning the use of the public purse to assist in rational and irrational suicides? The mood of the public and “the powers that be” have certainly changed since 1997 when Congress passed a law (still in effect) that denies the use of public funds to assist in assisted suicide, euthanasia, mercy killing, etc.. other than the form of suicide legalized in the 1991 PSDA)

    Because suicide is the fastest and cheapest/less expensive way to go for the patient, and Medicare/the state, and the private insurers, are “fiscal expediency” and “medical futility” and “assisted suicide” concerns compromising the autonomy of elderly patients who are terminal but who do NOT want to shorten their lives to shorten their suffering unto a certain death?

    Right now, under the law, Medicare patients cannot be forced onto Hospice but it looks like Medicare is planning a trial in the future that will perhaps mean that Medicare patients will LOSE their legal right to OPT or ELECT to give up their Medicare rights to take advantage of the Medicare Hospice entitlement. entitlement.

    A “form” of assisted suicide is already available in all 50 states under the 1991 Patient Self Determination Act (PSDA) wherein terminal patients can ELECT or CHOOSE to refuse any life-extending or life-saving treatment with an advanced directive. The 1991 PSDA together with the 1986 Medicare Hospice law opens the door to rational suicide by means of the elderly patient refusing food and liquid and fasting unto death while on Hospice care. The State is already legally assisting terminal patients in this more natural and rational form of rational suicide by means of the Hospice Entitlement, which is NOW elective.

    Those who advocate for assisted suicide wherein a physician has the power to write a lethal prescription that will result in instant death must reflect on the larger picture of how legalized assisted suicide by means of the legal lethal prescription will impact the autonomy of the elderly on Medicare/Medicaid who do NOT want to shorten their lives to shorten their suffering and save money for Medicare and the private insurers.

    Why would physicians want to have this kind of power to provide fast and instant death that so directly involves them in the death of the patient?

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  10. Steve Moffic

    Thank you so much, Carol, for your comments. You certainly broadened the discussion and,at least for me, added some new and relevant information. If I understood correctly, I, too, was trying to say that we could be headed to a slippery slope and that some could be pushed down it for fiscal reasons. As to your closing question, I would answer that if we think such a quick death would relieve unbearable suffering, and death was coming soon, that would be worth our suffering to do so, though of course this has to also be the choice of a physician to participate.

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  11. Steve Moffic

    This on behalf of Herb, who got an error message on submitting the following:

    “I was relating the changes in hospice care to your article. Having dealt with them through 6 parents and in-laws I have noticed a change in their administration of morphine. If the family does not have some degree of understanding many deaths are precipitated by too much and too frequently with justification. I could give you more details but this area is slowly becoming a disguised form of assisted suicide or a rush by hospice to speed things along. I admit in cases it is warranted and a blessing when there is much suffering.

    My main point is there seems to be a more aggressive shift in hospice policy and not sure the general public is aware or maybe even the mainstream medical community.”

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    • Steve Moffic

      Herb,

      These are important examples and points along the spectrum of “assisted” suicides. Maybe these would be better called physician-precipitated suicides? One has to wonder how common these are and what are the medical ethics justification. Does the patient know this is going to happen and therefore gives some sort of informed consent, and perhaps doesn’t want the family to know? Is the intent to reduce suffering? Something else? How do we find out more about this?

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  12. Herb

    Good points and questions, Steve regarding hospice. I can only speak from my personal experience with loved ones. Even though the hospice nurse works under doctor’s orders, the doctor in six of our family hospice experiences never saw the patient or talked with the family. Doses of morphine seem to be given with almost total nurse discretion. We happen to have a medical family so there were many times we refused efforts to medicate. I am speaking of last phases of life when our family members had no awareness or decision making ability. One example: my brother was with my father who was not aware of much but in no pain. The hospice nurse came in late while my brother was sleeping by his hospital bed. By the time he awoke he saw the nurse giving an oral dose of morphine. He asked why and she said he looked uncomfortable. He died about an hour later. Maybe it was a coincidence. Maybe not. My point in writing this is to ask is there a new trend in hospice? It may not be a bad trend but what are the guidelines, the ethics and how/why do nurses seem to have so much freedom. Many more questions but thanks again for your thought provoking article.

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  13. Steve Moffic

    ” . . . the doctor in six of our family hospice experiences never saw the patient or talked with the family.”(!)(exclamation mark mine). That certainly doesn’t fit medical ethics guidelines as I know them. How would a physician know best what is medically necessary for a patient or family without talking to them? Of course, if the patient is not responsive, the family becomes more crucial, with or without advance directives, I would think.

    The scenarios you describe suggest the goal of the hospice was just to aide the patient in dying quietly and peacefully, and maybe quickly. I suppose that saves money, but would not seem to lend itself to helping the family say goodbye and feel the best emotional resolution possible, especially if they were not part of the decision-making process. Besides the nurse coming in and out, were there social workers or psychologists that talked to the family?

    It would be helpful to hear from other people’s experiences around the country with hospice care. Perhaps that needs a large research project.

    -Steve Moffic

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  14. Carol Eblen

    In response to the comments, above. The Hospice entitlement passed by The Congress doesn’t anticipate that physicians will ever visit Hospice patients in their private homes. The per diem payments under Hospice are managed by the Hospice organization (most of which are NOW for-profit corporations) in the interests of the organization and the patient. I’m not sure that the law even requires Hospices to have a physician on staff in order to operate as a hospice. The lowest payment rate of $145.00(?) per day -per patient doesn’t make physician visits fiscally feasible. Unless the death of the patient is imminent, the Hospice patient may see a bath aid, a LPN/CPA and/or a RN only a few times a week for an hour or so until the final hours. When death is imminent, the hospice RN visits more frequently and the Hospice pastor will be on call. In residential nursing homes where Hospice is delivered, there is often a duplication of services that is now being looked at by the government.

    Remember! it is a family member or dear friend or paid helper who is the PRIMARY care taker when Hospice Care is delivered to a private home. The pain medication has to be managed in order to prevent emergencies and traumas for the primary care giver who is not a professional. If the patient is in great distress and pain, the primary care taker may break the hospice covenant and call Emergency when the Hospice nurse doesn’t get there soon enough, etc. and this could result in expensive ho9spitalization and death within the hospital. Most Hospice patients, necessarily, do sleep into death in the final days on Hospice because they are sedated to keep them and their care takers who love them out of pain.

    The Hospice law anticipates that patients who have six months or less to live and who have elected to give up their Medicare “curative care” to go on Hospice Care in the last six months of life will not need to see a physician and will not be hospitalized or go to the emergency room —unless the patient’s pain is such that it cannot be controlled in the setting of the private residence or a nursing home residence. In this event, the Hospice can order in-patient care in an in-patient Hospice.

    Remember, the promise of Hospice is death without pain and is the reward for giving up one’s rights to Medicare curative care in the last six months of life so that one can die in one’s own bed in one’s own residence whenever possible. It is a gift from government that has been abused and is open to misuse for profit, etc..

    It is the RN who is the case manager and who manages the care of the Hospice patient. It is the RN case manager who communicates with a physician and the pharmacist about the necessary pain medication that is often delivered directly to the patient’s private residence from the pharmacy and stored in the refrigerator in the private home for use of the Hospice personnel and the primary care taker.

    Remember that two of the goals of the 1991 Patient Self Determination Act together with the 1986 Hospice entitlement are to prevent over treatment of the elderly for profit and to save money for Medicare/private insurance when elderly/disabled patients on Medicare will ELECT to die outside of the expensive ICUs and CCUs of the nation’s acute care hospitals and die in their own private residence or nursing home residence.

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  15. Steve Moffic

    Thank you, Carol, for all this information. I believe Herb, in his comments, was talking about Hospice care outside of one’s home. From his point of view, it seemed like death might have been hastened inappropriately and that the involvement of a physician was desired. He was implying that maybe we are beginning to have a slippery slope in hastening death.

    You seem to be implying two obstacles to physician involvement in dying at home. One is reimbursement; the other seems to be the common desire of physicians to prolong life. However, it would seem like one home visit by a physician to the dying at home would not be financially too detrimental. Secondly, it would seem that physicians who are involved with hospice care would have more flexible attitudes about prolonging life or not. Whatever, in Herb’s case, what happened seemed to leave the family unresolved, which can adversely effect the grieving process. If the physician was even consulted by the nurse, apparently the family did not know that. Herb also suggest this was under-treatment, not over-treatment.

    Laws are one thing. How they are played out in real life care is another. As you said, most Hospice organizations are now for-profit. Is the desire for profit increasingly trumping what is medically and psychologically best for the patient and family?

    Prolonging death unnecessarily is one problem; hastening it inappropriately is another. How do we get toward the golden mean?

    When money takes priority over healthcare decisions, as it can in many (though not all) for-profit managed care systems, care of any sort can more likely be trumped by finances.

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  16. Steve Moffic

    I love Scott Adams, the creator of the Dilbert world, so creatively skewering the inhumanity of so many corporations (including in medicine). However, I was taken aback by just reading his new blog on his Website, titled “I Hope My Father Dies Soon”. I think the link is http://dilbert.com/blog/entry/i_hope_my_father_dies_soon/
    Here is one of the more gentle comments he makes: “If you have acted, or plan to act, in a way that keeps doctor-assisted suicide illegal, I see you as an accomplice in torturing my father, and perhaps me as well someday.” Of course, some of this may be part of his grieving process, and his father did die a few hours after he wrote the blog, but it is a startling statement from a cultural icon about how we can die so traumatically.

    -Steve Moffic

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  17. Carol Eblen

    Those who want to legalize assisted suicide by permitting physicians to write lethal prescriptions apparently don’t understand that the existing laws, the Hospice Entitlement under Medicare and the 1991 Patient Self Determination Act (PSDA), already legally permit patients to commit a
    “form” of suicide that is assisted by the Hospice entitlement.

    Patients, with terminal prognoses and pain and no chance of cure, can make known their desire to refuse food and water and they will usually die within six to twelve days —not in pain, because they are sedated during the final phase of the fast under the Hospice guidelines. Most Hospice patients sleep unto death peacefully in the final days of their lives when consciousness becomes too painful for them and their caregivers, often family members who love them.

    It is currently against the law for federal funds to be used to assist in Assisted Suicide, Euthanasia, Mercy Killing, etc.. for the obvious reason that state-sponsored killing of patients will be abused for the fiscal efficiency of the patient, the care givers, and the state/federal governments. Fast and easy death is, of course, the cheapest fiscal solution.

    Unilateral DMR Code status is already being misused to shorten the lives of those patients whose treatment will NOT be reimbursed by Medicare/private insurance under existing reimbursement protocols. .

    Suicide is no longer against the law in the USA when it is an autonomous act —rational or not —of the “terminal” patient.

    Those who bemoan being kept alive by the government want the government to condone and assist in their suicides but all patients have the right under existing law to choose to fast unto death under the auspices of a HOSPICE organization if and when they have been given a terminal prognosis by their treating physician.

    While I understand where Scot Adams is coming from, I would ask that he be careful and thoughtful about what he is asking the government to do.

    Do we want to change the law and allow our public Medicare Entitlement to be used to “off” the elderly and the “disabled” because of their shortened life spans and disabilities and because they are the logical targets for controlling the costs of “dying” in expensive ICUs and CCUs.

    Many of the experts believe that legalizing assisted suicide will take the doors off of the hinges and that passive euthanasia of the elderly/disabled for fiscal efficiency will become routine as Hospital Chains take over the delivery of health care in this country,

    It is the law and not poetry that is controlling in the matter of life and death in this country and the bioethicists need to look at the law.

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  18. Steve Moffic

    I am struck Carol, by the possibility that most bioethicists, administrators, and clinicians may not know all the laws and how to interpret them that you have told us. I suppose many others would have to respond to my wondering or a research survey done. For sure, I’ve learned new information from your comments, and again thank you for that.

    However, I think Scott Adams, in all his anguish, really does indicate what “is controlling in the matter of life and death in this country”. Although this may be my professional bias, I think it is neither the law, nor poetry, but psychology. Death, and the denial of death, in oneself and in loved ones, evokes such strong emotional reactions, including the unconscious repression of them, that reactions and decisions, even under the law, may not seem very rational.

    -Steve Moffic

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  19. Carol Eblen

    Yes! We have only “words” in the law and in our own vocabulary to deal with when we talk abou8t end-of-life options. But, I’m sure that you will agree that it is instinctive for all healthy-minded adults to fight death —to fight for one’s life —no matter the age of the patient –as long as the fight for one’s life has a good possibility of a cure and/or will provide enough extra “quality7″ time for the dying competent patient to close things out and say “goodbye” to their loved ones –that is, if the life-extending treatment isn’t found to be medically futile under some existing due process procedure.

    I agree that the scenario Scot Adams wrote about wherein his Father’s estate was paying to keep his Father in an Alzheimer’s unit is indeed a terrible ordeal and I agree that “advanced directives” should be made legal that will allow patients when they are first diagnosed with Alzheimer’s (when it is pertinent) to indicate in a legal document that they want to “fast unto death” –no food or water, etc., when the Alzheimer’s get’s to the point where they have to be hospitalized in special locked nursing home units –and pay for the care themselves. Nobody can visit these units and fail to see the suffering and waste and believe that these patients would want to live like this if they knew this was their FATE and the fate of their heirs.

    But! I believe that such an advanced directive for a FINAL FAST could be made legal, or may be legal now, if properly witnessed under State law and given to a Nursing Home and/or a Hospice provider.

    Surely, you are not suggesting that your “bias” is that physicians/hospitals should have the power to determine that competent patients are better off dead to protect their bottom lines when reimbursement protocols of the past ten years of Medicare and their private partners, Big Insurance, deny reimbursement to Hospitals/physicians for non beneficial over treatment of competent patients, mistakes, errors, and the complications thereof.

    Until IPAB becomes law and over treatment of the elderly on Medicare becomes almost impossible, the problem of overtreatment for profit that THEN often produces under treatment (also for profit) in the form of unilateral covert and overt DNR code status that results in euthanizing the elderly/disabled without their informed consent for fiscal expediency.

    Voluntary fasting unto death with the use of the Hospice Entitlement IS a RATIONAL form of suicide because the decision to fast is an autonomous decision of the patient which is protected under current law. It is NOT as fast or easy as Assisted Suicide with a lethal prescription but shouldn’t we err on the side of life and not promote suicide and death? .

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  20. Steve Moffic

    Thank you, Carol, for this continuing discussion. Though I hope others might weigh in, I would agree that we should “err on the side of life and not promote suicide and death”. However, I would not link physicians and hospitals together in addressing whether “competent patients are better off dead to protect their bottom lines”. Generally speaking, hospitals put the business ethics of bottom lines first, while physicians try to put the healthcare ethics of care and the reduction of suffering first. Often, this puts tremendous pressure of physicians to conform to the hospital’s priority. If anything, the “bias” in physicians is to prolong life, which sometimes contributes to unnecessary suffering for patients and families.

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    • Carol Eblen

      Thank you for responding to my comments –for talking to me! It is all in one’s perspective.

      It was my intention to link Hospitalists/palliative physicians and Hospitals together because the hospitalists work either directly or under contract for the Hospitals and these Hospitalists/palliative care physicians do have a conflict of interest when they KNOW that the treatment of a patient that they are seeing in the hospital may not be reimbursed under existing reimbursement protocols. The patient they are seeing in the hospital may have been over treated or have become the victim of an error in treatment in either the outpatient or inpatient setting. The patient may be a charity patient for the hospital.

      Do you agree that “sometimes” the “bias” by treating specialist physicians to prolong life is driven by the desire for profits because they are reimbursed up to the Diagnosis Related Group Cap for the cancer/disease being treated regardless of the advanced age of the patient and the stage of the cancer because of the federal Age discrimination statute?

      I have hoped also that others would weigh in on the discussion from their perspective but am not surprised that “death” is not a popular subject.

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      • Steve Moffic

        Maybe “bias” is the problematic word here. Nowadays, physicians in most any setting are faced with one or more ethical conflicts of interest. If still in solo private practice, there is an influence of wanting to make the desired reimbursement that can creep into patient care decisions. When salaried, there is pressure from the organization to serve that organization’s need. When a leader and administrator, one not only has to indirectly support the care of patients, but the needs of the organization, employees, and oneself. Add onto all of this the emotional volatility of dealing with the dying and their families makes ethical and rational decision making quite difficult for physicians at times. If anything, physicians are generally “biased” toward providing treatment for illnesses and reducing suffering, though even those two goals can come into conflict. Politics, business, healthcare, and death do not make easy bedfellows!

        -Steve Moffic

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        • Carol Eblen

          You are so right when you say that “Politics, business, healthcare, and death do not make easy bedfellows.”

          You bring up the fact that the “conflict of interest” cannot be avoided under any circumstances and this, of course, is true. However, there is a belief that the famous clinics, like Mayo, and the Cleveland Clinic, and the Academic institutions do deliver better care in terms of the diagnosis and actual treatment than private for-profit clinics and physicians’ practices –because these organizations are centered more on “good medicine” than “good profits.”

          What do you think of the EPIDEMIC of Hospitals purchasing Physicians’ practices and where do you think this will lead?

          Is the Hastings Center interested in this kind change in the delivery of health care, and how it will impact the patients?

          Apparently, some of this new organization of the delivery of health care will mean lack of autonomy for the individual physicians and a release from any conflict of interest concerning the patient? Will the Hospital’s owning the physicians’ practices result in more efficient and centered care of patients who will associate with a specific Hospital Organization who will provide lifelong “full service” health care including Hospice at the end of life?

          It does look like “Hospice” as a separate entitlement may not survive in its present form after the trial that Medicare/Hospice intends to run in 2014. The trial itself will mean that many more patients will die in Hospice and Not in the hospital, won’t it?

          I, as an elderly Medicare patient am not opposed to this as long as it doesn’t mean that my autonomy to choose to live or die is not removed —-except when “medical futility” can be proved under some due process procedure approved by the State —-such as TADA in Texas.

          Reply
  21. Steve Moffic

    For a very interesting discussing of the controversial Scott Adams blog mentioned above, see the article by Eric Zorn, “Cartoonist poses serious questions about dying” for the Chicago Tribune today. It and the interesting comments by the public can be found at http://www.chicagotribune.com/zorn.

    -Steve Moffic

    Reply
  22. Ronald Pies MD

    I appreciate Steve Moffic’s thoughtful and nuanced comments on this painful and complex topic. Having seen the long-lasting and traumatic effects of suicide in my own family (a dear uncle who had lost his job and became very depressed), this topic is of considerable personal interest to me.

    Whether there is such a thing as a “rational” suicide very much depends on what “rational” means, as Dr. Moffic suggests.
    The absence of a psychiatric disorder is surely no guarantee of “rationality”, if by that, we mean, “a state of mind in which one is capable of carrying out a realistic, evidence-based assessment of one’s own options and prudential interests.”

    For psychiatrists, the “rationality” issue is largely an academic and theoretical matter, since the evidence is very clear: the vast majority of suicides occur in the context of some ongoing psychiatric illness, especially major depressive disorder (MDD), which is known to affect judgment and rationality.

    More to the point: MDD is a highly treatable disorder, via
    appropriate psychotherapy and/or medication–and often, both.

    Finally–while there are always exceptions–I think it most useful to consider suicidal ideation as a “cry for help”, rather than as a well-founded or “rational” expression of one’s abiding wishes.

    Ronald Pies MD

    Reply
  23. Steve Moffic

    Thank you, Dr. Pies, for adding to this discussion and pointing us back to earlier times and interventions with your expertise about grief and depression.

    Let’s take this very day, Thanksgiving, as an example. If the family notices an elderly member who seems more down and/or anxious, and says stuff like this may be my last Thanksgiving, that is a clear indication to obtain a psychiatric evaluation to see if a clinical depression is emerging that can benefit from treatment. If ignored, the family member may get more and more depressed, perhaps be in more pain, and become suicide. Later, the interventions are harder and the suicide ideation can seem “rational”, when maybe the family member was just trying to ask for help in the only way they could at the time.

    -Steve Moffic

    Reply
    • Carol Eblen

      Yesterday, Thanksgiving, I woke up late and I was sad for a few hours. I am 86 and have celebrated many Thanksgivings over the years —some of which were happier than others —and now, in my old age, I think of my late Husband and Mother and MISS them. But as time goes by, I think of them more in LIFE than I do in their DEATHS, both of which I witnessed. I was the primary care giver for both my beloved husband and my beloved Mom, who had lived with me and my husband for over eleven years before she died.

      But! I am lucky. My children all live close and this allows me to stay in my own home, and I can afford to do this. I can still drive locally to bridge at my community centers and play bridge three times a week. I have good genes —my Mom lived until 104-l/2 and while my Dad died young with Hodgkin’s Lymphoma, three of his sisters lived into old age. I have a few good friends left –my daughter is my good and dear friend and I am not yet her “child.”

      I think of suicide only in terms of the “final fast” on Hospice which I di plan to engage in when I do finally suffer a terminal disease or become senile or have Alzheimer’s. I have given a Power of Attorney under Missouri law to one of my children. I believe I will have to make an actual Health Care Directive under Missouri Law in which I express my wish NOT to eat or drink when I am on Hospice before Hospice can honor my wishes under Missouri law.

      I think the “thought” of suicide has gotten millions of people through a bad night as it does give human beings the “control” that is taken away when things get so terribly out of control that they want to die. Isn’t this true?

      I have had mild attacks of depression throughout my whole life and have them even now but they don’t last for more than a day or so, and then I find “joy” again in living –until the next time.

      Because I had a traumatic experience with a unilateral and covert DNR, I have been obsessed with exposing this “systemic” violence on the Internet. I understand that this is a kind of therapy for me and I have already forgiven those involved because I understand that were I in the same position, I might have been capable of the same actions.

      I do, however, that that a unilateral and covert DNR is the worst kind of “elder abuse” and believe that the bioethicists should do their best to change present policy to make these covert DNRs impossible.

      Reply
  24. Steve Moffic

    Thank you, yet again, Carol, for sharing more of your personal perspective. Oftentimes, principles don’t match personal experience and needs.

    Yes, I think you are right about suicide thoughts being at times a way feeling one can control things that are getting – or can get – out of control. That is a prime reason why some commit suicide when the psychological and/or physical pain becomes unbearable.

    Disclosure of intent is virtually always important from a bioethical point of view. People and patients need to be able to trust caregivers and family when terribly difficult decisions need to be made. Given that mental status and emotional reactions can change, life and death decisions can become so complicated that ethics committees need to be involved. As our population continues to live longer, with more chronic medical problems, careful deliberation needs to be ongoing, I would think. This blog site is one good place to do so. The more that participate, the better. Sort of like a virtual town hall. That is why my next blog thanked those who set this site up.

    -Steve Moffic

    Reply
    • Carol Eblen

      You mention ethics committees BUT the in-hospital ethics committees have a serious conflict of interest with which I, personally, have had a personal bad experience.

      You might try reading the Medical Futility Blog by Thaddeus Pope, the foremost expert and historian on medical futility and the law to better understand the conflict of interest the hospitalist, the palliative care team, and the residents have when elderly/disabled Medicare/Medicaid patients are hospitalized.

      Thaddeus Pope recommends that ethics committees be regional and as free as possible from bias in the interests of protecting “due process of law” and “autonomy” for elderly/disabled patients when medical futility is invoked by the physician(s) and the patient or the patient’s legal surrogate doesn’t agree. See his comments on HEC’s.

      What is the purpose of the Hastings blog if not to contribute to the making of good public policy by our legislatures and Congress for those in the public who are patients?

      You can see by my postings that I believe that the bioethicists have failed the public at large because you do not concentrate on policy concerns but rather on “treatment” and its goals and your personal specialties. Of course, you are physicians and I understand this influences the bioethicist to begin with.

      I hold the bioethicists directly responsible for the tendency to treat unilateral covert and overt (default) DNR Code status as an “ethics” violation and not a crime or a tort as indicated in existing law. The solution you have advanced —Hospital Ethics Committees — is not a good solution for the patients.

      Reply
  25. Steve Moffic

    Again, we should hear from others, but the ethics committees that I served on were like Pope’s recommendation. It definitely is important to reduce conflicts of interest as much as possible, but sometimes that can’t be done completely.

    Reply
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