Doing the Right Thing

For the third time in a 50 years, it’s hip to talk about dying (except, perhaps, if you are in the middle of dying yourself). Interest seems to come in waves. First there was Elisabeth Kubler-Ross, whose book On Death and Dying, published in 1969, opened the curtains on life’s final act. Then came Sherwin Nuland in 1994, with How We Die: Reflections on Life’s Final Chapter. And now we have Atul Gawande with Being Mortal: What Matters in the End, along with several other important books, ranging from the Institute of Medicine report, Dying in America and, most recently, Angelo Volandes’ The Conversation, with its overstated subtitle, A Revolutionary Plan for End-of-Life Care. It’s good that we are talking about care near the end of life, and maybe this time the interest won’t sputter out before we actually do something to assure that all patients die with a minimum of pain and distress, in their homes if that’s where they want to be, and without unwanted medical technology. But what of the months and sometimes years before death, when so many people are neither robust nor dying, but somewhere in between?

Patients and doctors alike seem to want a black and white world, where you either focus exclusively on prolonging life or you focus exclusively on being comfortable. It’s either the ICU or hospice. Even Susan Jacoby, in her trenchant book Never Say Die, advocates that doctors “do everything possible only if there is a realistic hope that I can emerge as a functioning, mostly competent human being. Then stop and let me die.” She moves the bar demarcating intensive medicine and comfort care—she thinks comfort care should begin before dying starts rather than after it has begun—but her world is still black and white. What I am interested in, by contrast, and why I write about people who are frail and people in the early and middle stages of dementia, is the gray zone.

In the gray zone, people are not dying in any conventional sense. They are still living and may continue to live for some time—in the case of people with Alzheimer’s disease, perhaps even 5 years—but they have begun the final phase of their lives. They are beginning their final descent, as airline pilots so helpfully tell you a good half hour before you reach your destination, but won’t actually land for some time, and even then it will be a while before you arrive at the gate and can take off your seatbelt.

Who is in the gray zone? Principally people with either physical frailty or cognitive frailty (dementia). People who have a serious, ultimately fatal illness such as congestive heart failure or kidney failure or a progressive neurologic disease such as Parkinson’s or amyotrophic lateral sclerosis (Lou Gehrig’s disease). People who have a bad disease that will inevitably get worse and who have embarked on the spiral of relentless decline that will culminate in their death.

What approach to medical care makes sense for people in the gray zone? Not everybody wants the same thing, but it is my belief based on clinical experience, scientific evidence, and common sense that most people who are physically or cognitively frail favor what I call intermediate care. This is care that is focused on maintaining whatever functions the person still has—activities such as walking, talking, seeing, hearing, and thinking. Preserving functioning is the primary goal of care. It may not be the only goal of care: people in the gray zone will often wish to live longer, but only if the treatments intended to achieve this end do not further impair their functioning. People in the gray zone usually want to be comfortable (doesn’t everyone?), but they are willing to undergo some discomfort in exchange for the strong possibility of holding on to the functions they have.

What does intermediate care look like? We tend to talk more about what it excludes than what it includes. It excludes attempted CPR—because people who are frail almost never survive attempted CPR and if they do, it is likely to be in a state of far poorer functioning than before the cardiac arrest. It excludes treatments such as risky chemotherapy and treatment in the ICU for the same reason: these medical therapies are seldom effective in prolonging life in patients who are frail and if they succeed, the price is usually a decline in function. What intermediate care includes is treatments that are intended to maintain function, things such as cataract surgery or hip fracture repair. It includes life-prolonging treatments such as antibiotics for pneumonia or transfusions for gastrointestinal bleeding if they can be accomplished with only a small risk of deterioration in the person’s ability to function. That means it may well include hospital treatment, up to a point. The distinguishing features of intermediate care are both the benefits it is likely to confer (better functioning, possibly longer life) and the burdens it is likely to avoid (decline in precisely those areas that the patient values most, whether mobility or cognition or some other domain of daily functioning). Intermediate care can be high tech or low tech: the issue is not the complexity or the cost of the treatment, but its effects.

We need to let patients know they have entered the gray zone—if they mistakenly believe they will get better or they fail to realize they are dying, they will be unable to make wise choices about the kind of medical care that is right for them. We need to tell patients that there is such a thing as intermediate care and help them understand what it means in practice.