Tuesday, March 26, 2013

The View in the Rear Mirror

Just the other day, the high school classmate who has taken on the task of keeping all the members of our class in touch informed us that a classmate had died.  Now, this is not the first death, by any means.  As a class that graduated in the 1960s, we had a smattering of classmates lost to combat deaths.  And we have also had classmates who disease has over-taken.

This particular death notice did not really affect me much--frankly, I pulled up the wrong face from my mental file.  So, when I went to a yearbook to confirm my presumed image, I saw another face there.  So much for the accuracy of memory.

I find myself musing on the lives of both high school and college classmates.  Most of them I have lost touch with.  I have only attended one high school reunion--more on that in a bit--and two college reunions.  I confess, the first thing I did at all of these reunions is take furtive glances at the faces of these classmates, and wonder.  Those who I had envied most seemed not to have fared so well.  And, there were one or two whose now faces did NOT match up with my mental image, nor with their high school or college photos.  In fact, at one college reunion, I had someone come up to me and say--Remember me?  And I did not.  Then, when he told me his name, it was all I could do to refrain from saying--No, you're not.

I was only in the high school from which I graduated for two years--having moved around and attended various schools through my elementary schooling.  So, it was with some longing that I watched other students who had grown up together, and been pals since kindergarten.  I felt like an outsider.  But, I tried to compensate, and threw myself into various activities.  I tried out for sports--unsuccessfully.  I tried out for the school play--and did win a part...cast as the mother!  I was more successful in school chorus--a large enough group that my non-solo voice didn't matter.  I can definitely carry a tune, and I am a fairly decent alto.  The coup for me was getting admitted to National Honor Society, no mean feat considering my short tenure in high school.  So, it was the popular kids that I really wanted to see at the reunion.  And, therein, I found vindication.  Time had marched all over them, just as it does us all.

College was better, more rewarding, more welcoming.  And I find myself thinking about those classmates.  The reunions I attended there were not so much occasions for gloating, or grimacing--but more for commiserating.  We shared career and family news.  We traded maladies.  And we just enjoyed, for an afternoon, basking in the glow of remembering a time long ago. 

Not long after the last reunion, where I had learned of the serious and life-threatening illnesses two college friends had suffered, I got news that the classmate who had organized the reunion had triple by-pass surgery.  Time keeps marching.

There's no great revelation in all this musing.  It just occurs to me that though we have to live our lives going forward, we only really understand in reverse.  So, the view on the rear mirror lingers.  I find myself glancing backwards, almost as much as forwards.  But, I wonder--does the caution printed on the mirror apply?  Objects in the mirror are closer than they appear?  Or should that be further

Thursday, March 07, 2013


When is enough enough?

This past week, most of the various national news media carried the story of an 87 year old woman in an independent living facility in California.  She collapsed during lunch, and--in keeping with the policy in place at the facility--staff called 911 for an emergency medical transport to come.  The 911 operator asked about the woman's immediate state--was she breathing?  And when the staff person said that the woman was breathing only faintly, the 911 operator sternly instructed the staff person--you have to start CPR right now.

When the staff person, identified as a nurse, demurred, the 911 operator became very insistent and said--she might die.  And, therewith, the focus of the story became clear.  The only fault seemed to be the refusal of the nurse to begin CPR.

But there are other questions that should have been asked.  Did the 87 year old woman have an advance directive?  Did she want CPR to be given in the event that she suffered cardiac arrest or some other catastrophic health event? What did her family want for her treatment? How effective is CPR?  What were her chances of survival even with CPR?  Perhaps predictably, none of those questions was asked--the initial news coverage seemingly tripped over itself trying to make the story as negative and sensational as possible.  I must, however, give credit to NBC which did begin to raise the questions.

We have been so accustomed to seeing CPR performed as part of a dramatic scene in a television drama that we most likely assume it always works.  But does it?  The short answer is no. 

One website indicates that CPR is rarely effective:
  • 2% to 30% effectiveness when administered outside of the hospital
  • 6% to 15% for hospitalized patients
  • Less than 5% for elderly victims with multiple medical problems

Recently, my husband and I updated our wills, which--this time--included advance directives.  We want our preferences to be known to family and health professionals.  There comes a time when enough is enough.

This is not an easy subject to broach.  And the question goes beyond end of life care--it should even be raised in smaller ways.  Part of the reason that Medicare consumes the amount of money it does is because so many procedures are paid for.  True, they are paid for at Medicare's rate--but, to my knowledge, there is no information for patients that says "you don't  have to have every procedure a doctor recommends." 

I am currently helping my elderly father (93) and my step-mother (80) make various decisions.  I am struck by the number of times that a medical provider simply schedules the next appointment for 6 months.  True, these appointments are well-care appointments, and--generally--that is the best approach to medicine.  But when I picked my step-mother up from her recent dermatology appointment, the nurse scheduled her for a 6-month checkup.  So I pushed back a bit--why 6 months?  The nurse said--well, there' s a history of skin cancer.  So I asked my step-mother--how long ago?  She couldn't quite recall, but said nothing recently.  I have had multiple basal cell skin cancers--and I go for checkups once a year.

I suggested to my father and step-mother that they can decline to schedule appointments if they feel they are unnecessary.  To my thinking, this is especially true for simple skin care--skin cancers (other than melanoma) takes YEARS, even decades, to develop.  And is that a serious concern for someone in his or her 80s or 90s?  Please understand, I also ask myself the question--at my age. 

So, it all comes back to the question of when is enough enough?  I think part of American obsession with youth, with seeming never-ending life, feeds the tendency to think we must always intervene--always give CPR.  But, part of the human bargain is this: we are born AND we die. 

Sometimes enough is enough.