A Piece of My Mind
October 21, 2009

Can We Agree to Disagree?

Author Affiliations

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

JAMA. 2009;302(15):1629-1630. doi:10.1001/jama.2009.1422

I spoke to my 90-year-old grandmother, Anne, today about her goals for medical care as she reclined in her hospital bed. Our conversation resulted in a considerable amount of déjà vu. It was five years ago this month that I had had a similar conversation with her and my grandfather Phil—a conversation that changed the way that I, a geriatrician and hospice and palliative care physician, talk with patients and their families about advance planning for end-of-life care.

My grandfather had a history of diabetes, congestive heart failure, chronic renal insufficiency, and a host of other smaller medical problems that added up to a laundry list of medications and disability. Six months before his death, he was hospitalized due to a fall and a hip fracture. Hip surgery and a long hospital stay led to generalized deconditioning and extensive heel decubitus ulcers. What ensued was a horrible six-month ordeal of multiple transfers back and forth between the nursing home and the hospital for surgical wound care, infections, exacerbations of congestive heart failure, arrhythmias, gastrointestinal bleeding, and deep venous thromboses. Although his physical function continued to decline, my grandfather retained his mental faculties and was able to visit with my grandmother and other family. Despite my pleading, his physicians had not initiated a discussion about my grandfather's goals for medical care. His specialists and hospitalists continued aggressive treatments, including dialysis and surgical wound debridement, with little discussion about what he wanted.

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