“The medicine of this secular world may cost a fortune and take time to prepare. Also they may be bitter. Also, they may come with prohibitions, but those who rely on them for their lives continue to take them until they die. But now I present a method that does not cost a cent, does not waste even a half-a-day effort, is not bitter to the taste, and can be eaten and drunk as you wish. Nevertheless people do not seek to practice it, and ordinary people are not aware of its value. Perhaps its charm is too high, and few can appreciate it; this causes me great distress.”
This is a quote from Chih-I from the sixth century which could have been written just today. The cost of many medications prescribed for patients is in some cases so high people simply can not afford the cure. And almost all prescriptions come with a list of possible side effects that outnumber the benefits. Not that the possible side effects will happen but they certainly are cause for concern when taking medicines.
I’ve been following a Tweet thread that has been going on for several days concerning prescription medications, the elderly, fall risks, and medications that conflict with one another. While this has focused on prescriptions taken by the elderly it is equally true and of concern for anyone taking medications. The fact that some medications counteract with each other or even cause toxicity when taken together. Some medications are to be taken with food and some without. Some medications can be taken with certain foods and not with others. Taking prescription medications is complicated and the patient may not always be equipped with enough information to keep up with all this.
One point advocated continually in this Tweet conversation is using a single provider, one pharmacy as this will enable the pharmacist to examine the medications you are currently taking and advise you about possible harmful interactions. You would think your doctor would know this, but it isn’t always the case they know your prescription history. When I go to the VA hospital on every visit my doctor goes over the medications I am currently taking. I’m fortunate that I have a single healthcare provider in the VA.
For many people however because of various insurance policies their medical providers may change, or even the approved network hospital may change. This means that you may at some point be visiting a different doctor.
Also a pharmacist is more specially trained in the medications that are being prescribed. Your doctor may know of some of the benefits and some of the possible side effects, they may not be as well versed on interactions with other medications. That is a speciality of the pharmacist.
Whenever we are given a prescription medication it is important to weigh the potential for benefit alongside any possible negative consequences or potential losses and limitations from taking that medication.
Besides the plusses and minuses of various medications there are other areas to look at regarding benefit and loss. Several years ago I had to have rotor cuff surgery on my shoulder to repair a tear. The condition was very painful. The thing about a torn rotor cuff is the excruciating pain that comes up after you fall asleep, that is greater than any pain during the day. The reason is because when you fall asleep your arm relaxes and this causes the muscles both torn and good to not hold the shoulder in its socket properly; probably a bit more complicated than that.
Due to complications with getting needed insurance approval it took over six months from the initial diagnosis until the surgery. By that time the muscles in my shoulder and arm had atrophied so much that I had almost no range of motion. Additionally the joint had begun to calcify due to non use and the bones and begun to grow together in the shoulder socket. The surgery was the most painful I have ever had and I wish never to have it again. The surgery was bad and the six months of daily physical therapy afterwards was equally bad. At first to lift my arm off of my stomach where it was strapped after the surgery was something I could not do, the therapist would gradually every day lift it a little bit further while I lay there in agony. The millimeter lift felt as if he was twisting my arm behind my back.
I would come home from therapy everyday exhausted, completely spent from the pain I was experiencing. On the job I had to learn to do everything with my left hand, computer mouse, writing, eating everything as a lefty and everything as a one armed person. I was lucky that my job and insurance covered the therapy and the daily time off from work. That isn’t a benefit many people have. When I think back to the situation I can think of few benefits from the problem or the solution other than it got fixed. Even to this day I can’t put my seatbelt on, a right handed operation that I assist by putting my left hand under my elbow and raising my right further to grade the belt buckle and swing it around me.
Now if you take my brother’s heart attack it is a different story. It was relatively minor caused by some arterial blockages which stents were able to resolve. He did not need any major surgery. From that he used it as a wake up call to change his diet and exercise. We had always considered him ‘big boned’ a little chunky but certainly not fat. Now after several years of eating better, getting proper exercise he is actually completing in bodybuilding competitions in California. The last photo of him I saw a few months ago I told him it’s a good thing he wasn’t meeting me at the airport because I would not have recognized him, he has changed so much. So that was a clear benefit. Although it only became a benefit because of how he used the event to make decisions about his future.
Let me shift gears here a bit, still staying on loss and benefit though from a different perspective. In my time, and in every medical person’s time working in a hospital we all experience the coding of patients. Code is the jargon for a person’s heart stopping. As a chaplain we always attended every code. During the day time you went to codes in your unit and at night as the on-call you went to any and all codes. When they announce a code there is a rapid response team that runs, and I do mean runs to the event location. When that happens you get out of the way, someone’s life is depending on their arrival.
As soon as they arrive they immediately begin chest compressions, these are violent and continue until the heart starts beating or until the code is called, the patient pronounced dead. I have attended codes where by the time they finish the patient is little more than a rag doll, their chest having been compressed so much their rib cage is shattered. Sometimes it happens ribs puncture organs, not often but it does happen. To give you an idea, a big strapping muscular guy usually only lasts not much more than 10 minutes and usually less, though it can seem like hours. They constantly rotate the person giving the compressions, it is tiring.
There is a lot of controversy about allowing family to witness this procedure because it is so violent. When I first started at the hospital in Charlotte the policy was to remove family from the room, and the chaplains or the attending nurse would do this. If it was required to do that once I completed their removal I would return and pray outside the room. It is tough to watch this, very emotional especially knowing the procedure and the usual outcome. Yet families and patients want it done. Now the policy is to allow the family to watch the procedure being done.
I agree with the idea of family watching it. Sometimes families have unrealistic ideas and expectations. Let me say if you’ve ever taken CPR training with a dummy, you have no idea what goes on. Depending upon the body of the patient, their weight, fat, age, and so forth the patient at times literally bounces off the bed while the person doing compressions puts their entire weight into the compressions. Imagine a 180 pound person pressing their hands on your sternum with all of their weight behind that press, and then doing it several reps per minute.
One question asked of patients and also a question on Advance Directives or Living Will or other various names it can go by is do you want to be resuscitated? This is a standard question for anyone admitted into the hospital. If a person says yes then they are listed as full code, meaning if the heart stops then they get CPR. Now, I don’t know what you may think you know about resuscitating a patient but the only place I’ve seen ‘paddles’ use is on TV, not ever in the emergency room, not ever in the patient room, not ever anyplace in the hospital. So if that’s your thinking then it’s time for an adjustment.
If a person chooses not to be resuscitated then they are listed as DNR, Do Not Resuscitate. I am a DNR as well as DNI, do not intubate. When my heart stops it stays stopped. It is said that most medical professionals choose DNR, though I only know this from reading books, I never did a survey.
CPR can be a life saving procedure, a vital procedure. Though it is in rare situations that is true. It is beyond me to list when it is good and when not, its way more complicated than that. It is a choice everyone needs to make on their own and there are many factors as to why someone may choose one way and not another.
Let’s look at my life to illustrate some of the considerations in the decision making process. First I am 69 years old, I’ve lived a good life, a full life and a life much longer than almost all my friends. I’ve lived almost as long as the oldest recoded person in our family history. While I’m in no rush to get out the door, I’m also not resistant to leaving. At 69, my body and bones are not as strong as they once were though they are not as brittle as some at my age, I am male so bone density doesn’t decrease as rapidly as for women. Still I’ve seen what the body goes through in CPR and I don’t want that, I don’t want to wake up with a chest so sore I can hardly breath and for which there is no pain relief.
Other considerations are I have no spouse, my partner died before me so it is just me. I am not responsible for the care of anyone other than my dog, no one depends on me to continue living and providing support. I am fairly certain if I had a dependent my decision might be different depending upon other arrangements and what had been taken care of. If I had a spouse who depended upon me my decision criteria would be different. Certainly if I were younger, with a spouse and child or children my choice might very well be to have CPR and anything necessary done to try to keep me alive.
Our life situations can and should factor into our decisions regarding our health and treatment options. To ignore them can actually be more harmful than not. This is a situation we frequently would face in the hospital where a very elderly patient is listed as full code, meaning they wanted CPR. In all likelyhood if they survived the CPR they would suffer from various other complications such as broken rib bones for which nothing can be done and at an elderly age would take a long time to heal. Yet it is their choice. Sadly though many people don’t fully understand what they have chosen. A spouse may not be prepared to loose their loved one and so demand CPR even though that may actually be not appropriate for their body.
Another consideration that medical folks have information to which the general public doesn’t is that the rate of recovery from CPR on television is I think about 75% or greater. In the real medical world it is less than 10%, significantly less. Further, which isn’t always thought of is of those who are resuscitated in the real world a very small, less than roughly 5% live much longer than 2 or less years. My numbers may be old and I’ve rounded up so in all probability the percentages are worse. There are good reasons for doing CPR, they just aren’t always what people expect or think about.
I would hope that as an outcome of your reading this you will consider what are your conditions for living? In a general sense, because we never know exactly what we will face, what are you willing to have done to maintain your life. For me, I have ruled out any aggressive treatments, and especially ones that would significantly reduce my quality of life. For me at this stage and age of my life I am focused on quality and not quantity.
A younger person with more life ahead and with a younger body which would heal faster, the choice may focus more on quantity with quality being something to regain after recovery. There is no one right path, and it’s important to consider this now rather than wait for an emergency. Further even in an emergency you may change your mind, I certainly might change my mind. But I have thought about it and I’m prepared and most importantly I am clear on my goals and values. More than anything knowing your values, what’s important and why it is important as well as what are your goals regarding your health care and why, these if known can provide you with a basis for your decisions even if they may change over time.
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