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Join Althea Halchuck, a patient advocate. We explore critical insights into end-of-life care, the ethical considerations around antibiotic use, and the quest for a peaceful, dignified death. Delve into the complex world of health care decision-making in challenging times.

Althea Halchuck is a patient advocate.

She discusses the KevinMD article, “The old man’s friend: Refuse antibiotics to achieve a peaceful death.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today, we welcome back Althea Halchuck. She is a patient advocate. Today’s KevinMD article is titled “The old man’s friend: Refuse antibiotics to achieve a peaceful death.” Althea, welcome back to the show.

Althea Halchuck: Thank you, Kevin. Thanks for having me.

Kevin Pho: So Althea’s been on multiple times. Go to KevinMD.com/podcast, upper right-hand corner, search icon, and search for her name to find her prior episodes and hear her story. Today, let’s jump right into your KevinMD article, “The old man’s friend: Refuse antibiotics to achieve a peaceful death.” How did this particular article come together?

Althea Halchuck: I’ve always been intrigued by that phrase, “the old man’s friend,” and I began researching it for Final Exit. I’m their surrogate consultant, and I do a lot of presentations for them, so I checked it out: What does it mean? Where does it come from? People in the late stages of life, basically on their deathbed, can forego antibiotics and have a peaceful death. That was Osler’s phrase, a hundred years ago. He said it was the natural enemy of the old man, because somebody was basically on their deathbed, in a coma, and he didn’t have antibiotics back then. So it was just a peaceful death.

And when Bill Clinton went into the hospital, probably about a year ago, he had sepsis. He didn’t even know he had it. They gave him antibiotics, and they brought him back. But it got me thinking. I get a lot of requests from people like, “I’m done with life. What can I do? I have all of these problems.” They have no way that’s legal. They don’t live in a medical aid-in-dying state. Final Exit has a program, but it’s not for everyone. And if somebody has some kind of infection and they forego antibiotics, it’s legal, and it’s quick. According to the sepsis organization, it progresses rapidly and is a fast killer.

So here we have these people, and instead of curing them with antibiotics, I’m thinking, well, if they decide they want to go. I mean, this isn’t for everyone. I’m not suggesting people do this as a way to commit suicide, nothing like that. This is when people are at the end of their life, basically on their deathbed: Rather than keep being dragged back into living, which is not what they want, just forego the antibiotics. And I think what happens in a medical setting is that it’s the default. Somebody comes in with an infection, and boom, they get antibiotics.

There have been a couple of wrongful life lawsuits around this. The last time I was on here, I talked about the dentist in New York who had stage seven dementia. While he had capacity, he said, “No antibiotics when I reach that stage.” His wife said none. His POLST said none. His advance directive said none. And the doctor in the ER gave him antibiotics and brought him back to life. So now they have this big lawsuit in New York over antibiotics at the end of life. That’s kind of how it started. I just wanted to turn that thinking on its head: Instead of curing people, maybe it’s a peaceful way to go.

Kevin Pho: Now, from the clinician’s standpoint, talk about the ethical considerations they have to deal with when considering antibiotics at the end of life. What are the pros and cons? What are the ethical considerations clinicians are faced with in general?

Althea Halchuck: Well, I studied bioethics a lot in law school, and I was on two bioethics committees. For me, it’s all about autonomy. It’s about patient choice. And antibiotics and CPR, by the way, are two of the things where there’s no informed consent. Patients get them whether they want them or not. I understand clinicians wanting to save a life, but it’s really up to the patient and the advance directive. In the case of the dentist, he absolutely didn’t want it, and he lived another few months. So to me, patients should be asked, “Is this what you really want?” I heard from a couple of people on my blog who said, “I was in the hospital with an infection. They didn’t even ask me if I wanted an antibiotic.” Yes, they do want to save a life, but maybe they should be asking the patient what they want.

Kevin Pho: And from your experience, that anecdote you mentioned, about the patient not even being asked whether they want an antibiotic or not: Is that common?

Althea Halchuck: Oh, very. Medicare spends the most money at the end of life, and a lot of times it’s on somebody who’s in a nursing home. They get an infection. They bring them to the ER, pump them full of antibiotics and send them back to the nursing home. If it’s a 99-year-old person, do they ask the person? Probably not. Maybe the person doesn’t have capacity, so they’re making this decision for them. But I think it happens all the time. I think that’s the default.

Kevin Pho: Talk about the case you mentioned, the wrongful life lawsuit, Greenberg v. Montefiore Hospital. Talk more about that case.

Althea Halchuck: So Dr. Greenberg was diagnosed with dementia, and very early on he did his advance directive. He made his wife his power of attorney, and at some stage there was a POLST. Whether his wife signed it or he signed it, it absolutely said no antibiotics: “When I can’t recognize my family, don’t keep me alive. Let me go.” So he was in a nursing home, and he fell or something, and they brought him to the ER. His wife is there, and she’s telling this ER doctor, “No antibiotics.” She handed him the POLST: no antibiotics. You can look up the case and read about it. This is really what happened.

Most of the time, doctors weren’t liable for anything they did when they were trying to save a life, but that’s really changed. The new wave is, yes, you will be liable if you don’t follow the surrogate, if you don’t follow the advance directive, if you go against a POLST. So the family sued. At first it was thrown out of court, because that’s how it always was. And then finally, the last appeals court in New York, which was, I think, about a year ago, said, “No, this case can go forward.” You can sue the doctor and the hospital in New York for wrongful life, because he was kept alive for a couple of extra months when he didn’t need to be. They had to watch him suffer. He was curled up in a ball in the fetal position. If they’d just let him go naturally, which is kind of the point of my article, it’s a natural death. Why are we giving him antibiotics?

So I have a feeling this case will settle, pretty much no question about it, because once a jury hears all of this, that they kept this poor guy alive for no good reason, when people were standing there telling the doctor not to do this and he did it anyway. This is one of several wrongful life cases currently being heard across several states. It all kind of started maybe 10 years ago, when there was a big case in Georgia. That was putting a woman on a ventilator when she had said absolutely not. The granddaughter was her power of attorney, and she sued, and she won a million dollars. That kind of opened the floodgates, and these cases are all over the country. Every single day you hear about another one where somebody does something, puts in a feeding tube when somebody doesn’t want it. They’re keeping people alive against their will. There’s no discussion with the patient. It’s “This is what I’m going to do, whether you like it or not.” And so now people are pushing back on that.

And it’s not just several; it’s a lot. Once lawyers get their teeth into these kinds of cases, and really, for the plaintiff’s attorney, it’s a long wait, because you have to keep going through all of the state courts and then up to the appellate courts, and it just keeps going and going, and they’re mostly civil cases. You’re going to see more and more of it. I think what will happen is lawyers and hospitals and insurance companies will say, “Well, wait a minute. We’d better start training people in the ED to ask, ‘Does this person have an advance directive? Do they want CPR?'” Because that’s another big thing they do. They give a 99-year-old CPR when there’s a DNR there. It boggles the mind how much this happens, and it happens every single day in every hospital all over the country. So once money kicks in, and once lawyers kick in and say, “You really need to do some in-house training here,” the first thing is: Does this person want to be full code, or do they have a DNR? Do they want antibiotics or not? Antibiotics are treatment. And whatever happened to informed consent? It kind of falls by the wayside when whoever’s in charge says, “Oh, no, we have to do this.”

Kevin Pho: Now, through your advocacy efforts as they relate to antibiotics, what kind of response do you get from the medical community?

Althea Halchuck: I posted on LinkedIn, and one doctor was all outraged about it, as if I’m trying to kill people, and nothing could be further from the truth. I’m giving people a choice, which is what doctors are not doing. If you want to do this, this is a method. It’s one way of doing it. I wrote a blog on how to die in Arizona, because we don’t have medical aid in dying, and there was a whole list of things. Die naturally. Just because we have all this modern technology doesn’t mean we need to use it. If people want to go, here’s A, B, C, D, E, and refusing treatment, not just antibiotics. It’s a lot of treatment: feeding tubes, ventilators. They keep people alive because they can, and to have no quality of life and be hooked up to machines in a hospital, I don’t know anybody who wants that.

Kevin Pho: So share your ideal scenario, in your ideal world. Let’s say a patient comes to the emergency department, perhaps at or near the end of their life, and they come in with symptoms suggestive of an infection. Walk us through what your ideal scenario would be.

Althea Halchuck: If the person has a POLST or an advance directive, they should absolutely have that as their guide. If they come in with a surrogate or a power of attorney, or even a family member, if it’s an older woman and her elder daughter comes in and knows what her mother wants, you should be asking that person. You shouldn’t just be doing what you want to do. They’ve taken the patient out of the equation. My ideal scenario is: Bring the patient back in, bring the family in, and talk to them about what this person wants. “We’re going to try to give them antibiotics, and that’s going to bring them back to go back to a nursing home where they have dementia. Do you want us to do that?” It’s so simple. “Do you want us to keep them alive with no quality of life, on a ventilator, with a feeding tube? Do you want that? Do they want that?” That’s the important thing. It’s the patient. It’s what they want, how they want to live, their values. That’s being left out of these discussions.

So ideally, it would be a family meeting, and they would all talk about their mom, what she stood for and the conversations they’ve had with her through life: “No, I’d never want to be hooked up to machines. I want to die at home.” That kind of thing. It’s sort of “Because we can do it, we will do it.” And I think we need to get away from that kind of thinking.

Kevin Pho: Talk us through one of these conversations patients should have, either with their families or their primary care physicians, as it relates to some of the things that come up during end-of-life care. Could they say no to things like CPR and being hooked up to a feeding tube, and yes to antibiotics, or is it an all-or-nothing thing? Talk us through some of the considerations patients should have when discussing their end-of-life care.

Althea Halchuck: I don’t think it’s all or nothing, because of the POLST forms I’ve read, and I’ve read quite a few of them. They’re all different for every state. You can have some, you can have none, or you can have everything. So it’s really up to the person. I think what people see on TV with CPR is never how it really works. CPR works, I think I just read, 13 percent of the time with healthy people. So if you’ve got somebody who’s not healthy, it’s like 1 percent of the time. Show them a video of what happens when somebody’s sternum breaks from CPR. They have this glorified version of it. Maybe if they were given the facts. There’s a guy, and I can’t recall his name, who developed videos with his wife, who’s also a doctor, to show people what these things look like. And when people saw what they looked like, they said, “Give me a DNR. If I have to go through that, if I have to wake up practically brain dead, or with a broken sternum, or with my rib going through my lung, that’s probably not for me,” especially if they’re 90 years old or 100 years old. They do it every day on people this age, and for what, I don’t know.

By the way, and I’m going a little off topic here, I had a friend who brought her father to the emergency room. This was about the third or fourth time. He had a signed DNR. When she brought him to the ER, that never translated to his chart. She looked at his chart, and he was full code. He had a brain bleed, and he didn’t want to be full code, so she had to actually change it. The Epic system defaults to full code, and I see that as a big problem, because you’re bringing your 95-year-old father into the ER because he’s got a brain bleed. You’re thinking, “We have a DNR. He has it in his advance directive.” You’re thinking you’re all set, and then all of a sudden you’re not all set. And you don’t find out until you see the doctor doing CPR and you look at his chart and it says full code. So I think that’s an issue too. Why aren’t we listening to patients? Why aren’t we helping them understand what some of these treatments do?

Kevin Pho: Now, with antibiotics specifically, what kind of questions should patients or their surrogates ask themselves about whether they would want to receive antibiotics in their end-of-life orders?

Althea Halchuck: Well, in the case of the doctor: Do you want to be kept alive if you have dementia and you don’t recognize your family? Do you want to be kept alive if you have congestive heart failure and you’re all bloated, and you know what it looks like? Do you want to be kept alive in those circumstances? These are the conversations people need to have with their primary care doctor and the attending, and they’re not having them. Doctors don’t want to talk about death, and sometimes they just don’t get it. So I think it depends on the patient, on their health condition, whether they’ve said, “You know what? I’ve had enough.”

My 95-year-old aunt was diagnosed with colon cancer, and they wanted to give her a colonoscopy. Like, what? We know she has colon cancer. Are we going to change what we do down the road if we do a colonoscopy and she survives it, by the way, at 95? Are we going to change the treatment? No, because she didn’t want treatment. So it’s things like that, where it’s almost like a reflex with medical staff: “OK, we’re going to do this because we have to find out.” So really, you need to know what the person’s condition is and go from there. Have the conversation with the people.

Kevin Pho: We’re talking to Althea Halchuck. She’s a patient advocate. Today’s KevinMD article is titled “The old man’s friend: Refuse antibiotics to achieve a peaceful death.” Althea, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Althea Halchuck: My take-home messages would be for both doctors and patients, but mostly patients and families. You have to advocate for yourself. There are lots of patient advocates around, but we charge a fee for that, and we tell you to advocate for yourself. They come in the room, and they don’t even tell you what they’re doing. I’ve been in enough hospital settings: They come in with a bag, they hang it up, and it’s full of antibiotics, but you don’t know that. You need to ask, “What is it you’re doing? What’s in the bag? What do you hope to accomplish? Why haven’t you asked me if it’s something I want or not?”

And granted, they’re busy, busy people. Nurses especially basically run the hospital. It’s all about time and money, and they don’t have time to go through it all. But you need to make them, because informed consent is your right. It’s a federal law that you’re allowed to hear the information, digest it and see if it’s for you. It’s all about patient autonomy, and again, the patient is being left out. So the family has to stand up and speak for the patient if they can’t speak for themselves.

Kevin Pho: Althea, thank you so much again for coming back on the show and sharing your time and insight.

Althea Halchuck: Thank you, Kevin.