The care of the elderly in this country is a national scandal, and it reflects the values and priorities of the nation as a whole, not the doctors who provide the care. The senile elderly are warehoused in nursing homes, sentenced to an existence that no one would want. When, as is appropriate for their age and condition, they try to die, they are shipped off to the hospital to be treated and then shipped back to the nursing home to be warehoused into the future. The lengths that we will go to continue this “care” are truly absurd. Consider the case of Ida for whom we convened court in the hospital in the middle of the night during my internship year.
Ida was 100 years old and suffering from a severe bed sore on her ankle so deep that her leg bone was exposed. The voluminous medical record revealed that Ida had led a wretched life. Throughout her 20s and 30s she had been repeatedly hospitalized for psychotic episodes. At age 40, her family had permanently committed her to one of the state’s mental hospitals, where she had remained until well into her 60s when she was transferred to the nursing home. Ida had never recovered from her psychosis, even as she slipped into senility. For the past 20 years, she had been completely incapacitated and had not been heard to speak a single word nor could she understand anything said to her. Beyond being able to experience pain, it appeared that Ida had no comprehension of the world around her.
They must have been taking fairly good care of Ida at the nursing home because she was in good shape for someone who could not care for herself in any way. They fed her and cleaned her, but they obviously did not move her around very much. Over the years she had permanently contracted into a fetal position. She could only be placed on one side or another. That was why she had developed the bedsore near her ankle. Now it was infected and threatening her life.
We treated her with antibiotics, pain medication, and supportive measures, but we could not gain control of the infection. If she were younger, the next treatment would be to amputate her leg below the knee, but that seemed to be far too aggressive for a woman who was 100 years old and completely unaware of her surroundings … or so I thought. Normally, Ida’s family would decide on the next step, but she had no surviving family. She had never married, and her closest relative, a niece, had died 15 years before. Therefore, we would have to ask the court.
The court appointed a legal guardian for Ida to represent her interests in the case. The guardian felt that it was very important for the judge to see Ida, and as Ida could not come to court, the court came to Ida. One evening, the judge and the guardian came to the hospital to hold a hearing. We explained the situation and recommended that Ida should not be subjected to the pain of an amputation, and simply be returned to the nursing home where should would die within a few weeks. The guardian, in keeping with his job, argued strenuously that the fact that Ida was 100 years old and uncomprehending should not be a reason to deny her the most aggressive care possible. The judge, to his credit, visited the bedside and insisted that we take off the dressing so he could see the extent of the bedsore and the infection.
It seemed to me that the judge was uncomfortable with the decision that he ultimately reached. He ruled that there was no reason to treat her any differently simply because she was 100 years old and uncomprehending. We were required to amputate her leg and to do it as soon as possible. Neither the chief resident nor I were happy with this decision, but the chief resident was philosophical.
“Look at it this way,” he said, trying to cheer me up. “It will be a great experience for you, because I’ll let you do the case. You can chop her leg off!”
We took her to the operating room that night. The chief resident carefully dissected the muscles away from the bone and tied off the blood vessels. He handed me the bone saw, and I did indeed saw her leg off below the knee. I was not appreciably cheered by the experience, however. I could not stop thinking that we had committed a great injustice.
It took almost a month for Ida’s leg to heal, but it did heal. It took several weeks more for me to arrange her transfer back to the state nursing home. When I got the call one morning that the nursing home finally had a space available, I completed the paperwork in record time and arranged for the ambulance to take her back. By lunchtime, we were celebrating Ida’s departure.
Later that afternoon, the chief resident came to find me. He looked grim.
“It’s Ida,” he said.
I was confused. How could we be having a problem with Ida; we had sent her back.
It turned out that Ida, no sooner having been returned to her bed at the nursing home, had promptly died. That was hardly surprising; she was 100 years old. However, Massachusetts state law mandates official investigation of any death that occurs within 24 hours of release from a hospital. Ida’s case was going to be referred to the Medical Examiner, and the chief resident and I were facing the possibility of a trial to determine whether we had played a role in Ida’s death. Fortunately, the Medical Examiner has discretion over which cases proceed to a full blown investigation and he ruled that she had died of natural causes and that no further investigation would be necessary.
To me, the entire episode seemed like a cruel farce from beginning to end. Why were we keeping Ida alive in a nursing home when she was completely unaware and had no hope of recovery? Why did Ida get transferred to the hospital for treatment of her infection? Why did we go to the trouble of convening the court at the hospital in order to decide Ida’s fate? Why did the judge insist that we amputate her leg to preserve her life?
At every step of the way, I did what I was told, because that was my job. Ida paid the price as we senselessly prolonged her life by amputating her leg, and subjecting her to the only thing she could perceive: discomfort. At no point during the proceedings did anyone, doctors, legal guardian or judge, stop to consider whether Ida, or anyone, would have wanted the “care” we were offering. Indeed, I have no doubt that none of us, doctors, guardian or judge, would ever have opted for the treatment that we forced Ida to undergo simply because she could not speak for herself and tell us to stop.
