PRINCETON – Pneumonia used to be called “the old man’s friend” because it often brought a fairly swift and painless end to a life that was already of poor quality and would otherwise have continued to decline. Now a study of severely demented patients in Boston-area nursing homes shows that the “friend” is often being fought with antibiotics. Such practices raise the obvious question: are we routinely treating illnesses because we can, rather than because we ought to?
The study, carried out by Erika D’Agata and Susan Mitchell and recently published in the Archives of Internal Medicine, showed that over 18 months, two-thirds of 214 severely demented patients were treated with antibiotics. The mean age of these patients was 85. On the Test for Severe Impairment, where scores can range from zero to 24, three-quarters of these patients scored zero. Their ability to communicate verbally ranged from non-existent to minimal.
It isn’t clear that using antibiotics in these circumstances prolongs life, but even if it did, one would have to ask: what is the point? How many people want their lives to be prolonged if they are incontinent, need to be fed by others, can no longer walk, and their mental capacities have irreversibly deteriorated so that they can neither speak nor recognize their children? In many cases, the antibiotics were administered intravenously, which can cause discomfort.
The interests of patients should come first, but when it is dubious that continued treatment is in a patient’s interests and there is no way to find out what the patients wants, or would have wanted, it is reasonable to consider other factors, including the views of the family and the cost to the community. Medicare costs for beneficiaries with Alzheimer’s disease were $91 billion in 2005, and are expected to increase to $160 billion by 2010. (For comparison, in 2005 the United States spent $27 billion on foreign aid.)
Moreover, D’Agata and Mitchell suggest that the use of so many antibiotics by patients with dementia carries a different kind of cost: it exacerbates the growing problem of antibiotic-resistant bacteria, putting other patients at risk.
Pneumonia also has not been able to play its friendly role for 84-year-old Samuel Golubchuk of Winnipeg, Canada, who for years has had limited physical and mental capacities as a result of a brain injury. Golubchuk’s doctors thought it best not to prolong his life, but his children, arguing that discontinuing life-support would violate their Orthodox Jewish beliefs, obtained a court order compelling the doctors to keep their father alive.
So, for the past three months, Golubchuk has had a tube down his throat to help him breathe and another in his stomach to feed him. He does not speak or get out of bed. How much awareness he has is in dispute. His case will now go to trial, and how long that will take is unclear.
Normally, when patients are unable to make decisions about their treatment, the family’s wishes should be given great weight. But a family’s wishes should not override doctors’ ethical responsibility to act in the best interests of their patients.
Golubchuk’s children argue that he interacts with them. But establishing their father’s awareness could be a double-edged sword, since it could also mean that keeping him alive is pointless torture, and it is in his best interests to be allowed to die peacefully.
The other important issue raised by Golubchuk’s case is how far a publicly-funded health care system such as Canada’s has to go to satisfy the family’s wishes. When a family seeks treatment that, in the professional judgment of the physicians, is not in the patient’s best interests, the answer should be: not far at all.
If Golubchuk’s children can convince the court that their father is not suffering, the court might reasonably order the hospital to grant them custody of their father. They can then decide for themselves, at their own expense, how much further treatment he should have. What the court should not do is order the hospital to continue to care for Golubchuk against the better judgment of its health care professionals. Canada’s taxpayers are not required to support the religious beliefs held by their fellow-citizens.