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Wednesday, January 11, 2012

When Will We Die?

The most recent issue of the Journal of the American Medical  Association has an important article, with an accompanying editorial, on the effort to predict life expectancy for patients over 60.

My armchair research (conversation with friends) suggests that our Medicare cohort has two antithetical fears about longevity and medical treatment. Some fear we'll be flogged with aggressive interventions way beyond the point of usefulness. Others fear we'll be consigned to the grave too quickly, and even if not actually buried alive, won't be offered interventions that could reasonably be expected to provide significant quality of life.

I'm on a week's holiday in Puerto Rico. This morning another guest was playing good tennis on the adjacent court. When we chatted later he told me he'd had a total knee replacement two years ago. He enjoys skiing and tennis. He's experienced impressive improvement in the quality of his life.

In contrast, 13 years ago my beloved father-in-law, 90 at the time, experienced angina that limited his walking. His physicians recommended a surgical revascularization procedure. He was an activist, and without telling anyone in the family until the night before he went into the hospital, scheduled the surgery. The results were catastrophic - an extended period of delirium and progressive heart failure. He declined rapidly and died after a few miserable months. Poignantly, his oldest grandson's best friend is a distinguished cardiovascular epidemiologist. Had he been consulted, he would have given a strongly evidence-based recommendation against the procedure.

My father-in-law was a thoughtful, forgiving man. He said  "my doctors were young men [i.e., in their 50s]. They were thinking about young hearts, not about 90 year old hearts."

The article identified 16 systems of prediction that show reasonable accuracy, but none were good enough to be recommended for routine use in practice. The editorial urges physicians to (a) consult readily available life tables (predicted longevity by age, race and gender) and then (b) consider individual factors. Here's the relevant passage:

These calculations could be facilitated through use of an electronic comorbidity and functional status. Lung disease requiring regular use of corticosteroids or supplemental oxygen, New York Heart Association class III or IV congestive heart failure, renal disease requiring dialysis, advanced dementia, inability to walk more than a block, and need for personal assistance with bathing are examples of factors that would reduce life expectancy substantially below the average. The absence of significant comorbid conditions or functional limitations would identify older persons who are likely to live longer than average.
As a starting point, age-, sex-, and race-specific life expectancies (median and interquartile range) can be calculated using data from standard life tables.
The authors have created a remarkable website - ePrognosis - that allows health professionals (identified by self report) to apply relevant tables to their patients. They've also created GeriPal (GERIatrics and PALiative care), a blog for health professionals and others interested in care of the elderly and palliative care. I'm proud that one of the sponsors - Dr. Alex Smith - did his primary care residency in the program I teach in. ( He was a star!)

Conversations based on life tables, individual status, and the patient's guiding values, won't achieve mathematical certainty. But they're crucial elements of wise, compassionate health care decision-making. It was monstrous when politicians branded support for this form of humane medical practice "death panels." We Medicare folks need to fight that form of demagoguery!

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