Your ailing parent is rushed to the hospital. Among other critical symptoms, he or she is having trouble breathing, so the emergency room physicians sedate your loved one and insert a breathing tube. Mechanical breathing keeps respiration going while doctors deal with the other medical challenges. All appears to be well.
Last Opportunity to Speak?
Or is it? We just read this troubling article that appeared last week in the pages of the New York Times. The title: “Breathing Tubes Fail to Save Many Older Patients.” The gist of the article is simple: the common practice of inserting breathing tubes into patients, called “intubation,” may be much more dangerous to frail seniors than previously thought. Equally troubling, because the practice makes speech impossible, doctors may be unknowingly robbing families of their last opportunity to communicate with someone they love. As the subtitle of the New York Times article warns, “One-third of patients over age 65 die in the hospital after they are put on ventilators. Doctors are beginning to wonder if the procedure should be used so often.”
The Times article talks about a new study recently published in the Journal of the American Geriatrics Society, authored by Boston physician Dr. Kei Ouchi. “I used to be very satisfied putting patients on a ventilator,” Ouchi told the New York Times, convinced that the procedure saved lives. “Like all emergency doctors,” writes the Times, “he’d been trained to perform the procedure – sedating the patient, putting a plastic tube down his throat and then attaching him to a ventilator that would breathe for him. But, he said, ‘I was never trained to talk to patients or their families about what this means.’” Ouchi began to realize that the outcomes for elderly patients going through intubation were nowhere near as positive as for younger patients, and often families facing a medical crisis were completely unaware of the risks and alternatives.
Alarming Discharge Statistics
Dr. Ouchi’s study gathered data from more than 260 hospitals nationwide and looked at outcomes from more than 35,000 intubations (also called mechanical ventilation) of patients over 65. According to the data, despite going through intubation, about one-third of the patients died in the hospital. But for the survivors, there was another issue. “Of potentially greater importance to elderly patients – who so often declare they’d rather die than spend their lives in nursing homes – are the discharge statistics,” reports the New York Times. “Only a quarter of intubated patients go home from the hospital. Most survivors, 63 percent, go elsewhere, presumably to nursing facilities,” either as long-term residents or for short-stay rehab.
The study further demonstrated a major difference in the outcome of intubation based on the patient’s age, largely due to the medically invasive nature of mechanical ventilation. “All intubated patients proceed to intensive care,” says the New York Times article, “most remaining sedated because intubation is uncomfortable. If they were conscious, patients might try to pull out the tubes or the I.V.’s delivering nutrition and medications. They cannot speak.” The Times quotes Dr. Ouchi: Intubation “is not a walk in the park,” he says. “This is a significant event for older adults. It can really change your life, if you survive.” And those survival rates are strongly linked to age.
“After intubation,” the New York Times reports, “31 percent of patients ages 65 to 74 survive the hospitalization and return home. But for 80- to 84-year-olds, that figure drops to 19 percent; for those over age 90, it slides to 14 percent.” Other studies have shown that while frail seniors generally see their health decline following any stay in intensive care, those who experienced intubation suffered twice the mortality rate.
A Promising Alternative
Is there any good news in the New York Times report? One encouraging trend is the increasing use of what doctors call “noninvasive ventilation,” which primarily means a device called a “bipap” – bi-level positive airway pressure. “A tightfitting mask over the nose and mouth helps patients with certain conditions breathe nearly as well as intubation does,” says the Times, “but they remain conscious and can have the mask removed briefly for a sip of water or a short conversation.” Most patients using bipap survive their hospitalization, and because they can be treated on ordinary hospital floors, they avoid the trauma of ICU.
But the time to have the conversations about preferred levels of care is before the health crisis arises. In the words of the Times article, “The harried emergency room environment…hardly encourages thoughtful discussions about patients’ prognoses and wishes. Those can become fraught conversations anyway.” Our recommendation at AgingOptions is to discuss your medical wishes, especially those involving end of life, with your family well in advance and to document your desires properly. We also strongly advise our aging clients to seek the medical advice of a geriatrician as your primary health provider. As a physician properly trained in the unique health care needs of seniors, a geriatrician can best advise you not only on how to stay healthy but also on how to make decisions that will preserve your health should hospitalization prove necessary. Contact our office and we will refer to you a geriatrician who practices near you.
The Power of Planning
Planning for the future where your health (mental and physical) is concerned can certainly be a challenge. But our answer at AgingOptions is not to focus strictly on one aspect of retirement planning, such as health care or finances, but instead to consider the totality of your life in retirement: health care, financial security, housing needs, legal protection, and certainly family communication. Without planning for all these critical elements, your so-called retirement plan will prove incomplete: but with these aspects all working together, you’ll have the safe and secure foundation on which to build the retirement future you’ve always dreamed of.
This process is called LifePlanning, and we encourage you to accept our invitation and join Rajiv Nagaich from AgingOptions at one of our highly popular, information-packed LifePlanning Seminars, offered absolutely free at locations throughout the region. Visit our Live Events page for details of all currently-scheduled seminars – then register online or call our officer during the week. Odds are you’ll have many happy and healthy years ahead of you once you retire. Enjoy them – and be prepared when a health crisis does strike – with a sense of freedom and safety, thanks to the power of your LifePlan. Age on!
(originally reported at www.nytimes.com)