end of life care


Palliative Care – Not Just for the Dying

I used to think that palliative care was just for people who were dying. Then I found out—about a dozen years ago—that palliative care had expanded its original focus on end-stage cancer patients to include people with serious illness throughout the course of their disease (or diseases). Palliative care, I realized, is far more than […]

Caring for Nursing Home Patients under Medicare

What drove me crazy about practicing medicine in a nursing home wasn’t the patients, although with their many medical problems often including cognitive impairment they were a challenge; and it wasn’t the families, though with their anxiety and attentiveness and sometimes their guilt they were an even greater challenge. What drove me crazy about nursing […]

Seventy-five Year Old Doctors Talk about Death

Here’s what George Eliot wrote in Silas Marner about how the elderly contemplate the prospect of death: “…it is often observable, that the older a man gets, the more difficult it is for him to retain a believing conception of his own death.” I observed the opposite at my fiftieth medical school reunion in June. […]

Dementia and the Goals of Care

Even though you think and behave perfectly normally, you might already have Alzheimer’s disease. In fact, you might warrant the label of “pre-clinical Alzheimer’s disease” for a full 20 years before graduating to the full-fledged condition. That according to the latest definition of Alzheimer’s put forward by the National Institute on Aging together with Alzheimer’s Association […]

Who’s Responsible for Granny?

On July 30, 1965, when President Lyndon B. Johnson signed the bill that created Medicare, he outlined an ethical vision for the nation’s obligations to its older citizens. “No longer will older Americans be denied the healing miracle of modern medicine,” he said. “No longer will illness crush and destroy the savings that they have […]

Keeping Frail Elderly out of the Hospital

When I was a medical resident at Boston City Hospital, a large, public, inner city hospital, I began wondering whether hospitals sometimes caused as many problems as they cured. Over and over, I saw older patients admitted with one disease such as pneumonia or a heart attack, who ended up falling and breaking a bone […]

Pulling the Plug on DNR

Recently, a friend commented that she was not sure whether or not to agree to a “DNR order” for her 90 year-old mother. Her mother has dementia and lives in a nursing home; she is her mom’s health care proxy. Complicating her decision was the knowledge that her mother had chosen a DNR status when […]

Surrender at the End of Life

First, the problem “Do not go gentle into that good night… Rage, rage against the dying of the light.” So wrote the Welsh poet, Dylan Thomas. Working intensively over the past seven years in end-of-life care, I have often seen this attitude as a response by good people to the bad things that are happening […]

Avoiding Futile Care and Reducing Medicare Costs

If we in the U.S. ever hope to get a grip on Medicare costs, our society will first have to navigate a steep learning curve. That’s the lesson to take from three recent publications.  Despite the fact that Medicare is expected to represent 18% of the federal budget in 2020 (up from 15% in 2010), […]

No Sense, Lots of Dollars

Twenty-five years ago, discussions of medical futility were the rage in bioethics circles. The discussions petered out when it became clear that futility was in the eye of the beholder: physicians and patients often had very different ideas about what futility meant, depending on what they hoped medical treatment would accomplish.     In one […]