Healthcare crises are of many sorts. The young family provider felled by a sudden disease or a young mother lost to cancer are all major family tragedies. However, in all families the inevitable eventuality is the death of aged parents. As I often used to say to my contemporaries, the fifties are often a difficult time for most of us. On one end we have the responsibility and the continuous worry of raising children and on the other end we have the inevitability of our parent’s sickness and death.

A peaceful and a relatively painless death in old age was once considered a blessing. But as medicine advanced and death became delayed, average ages increased and main causes of death in old age could be treated and even cured. Infection in the lungs (pneumonia) was called an old man’s friend. Lung infections would strike rapidly and cause an essentially ‘painless’ death, the sort of death that most old people would have welcomed in the old days. But that was then. Today much has changed.

The major difference today for those that can afford it is that a loved one is just not allowed to die from old age anymore. The poor have no choice because they just do not have the financial wherewithal to pursue excessive end of life medical treatment. Today you die of a specific disease that can and has to be treated until the bitter end. At this point, of course, many will immediately start blaming doctors for suggesting treatments that are expensive and perhaps do not help to prolong life or restore ‘normal’ activity. Well, doctors only get involved in such situations when a family brings their ‘dying’ relatives to the hospital or a doctor’s clinic.

Over many decades of medical practice, I have often been confronted by family members that insisted that all that could be done should be done to keep their loved ones alive. Today, medicine has become sufficiently advanced that it is possible to keep people alive for extended periods of time using different types of ‘life support’ mechanisms. But such life cannot be called living. We can breathe for patients using mechanical respirators, we can help failing kidneys using emergency dialysis, we can feed patients that cannot eat through tubes placed directly in the stomach and yes we can even use artificial mechanical hearts to keep people alive whose hearts have failed.

The problem is that most of the technology mentioned above requires ‘intensive’ medical support and care that is expensive and can be a devastating and even bankrupting financial burden on many of the families involved. In the United States, a significant component of insurance funds from Medicare (old people’s insurance) are expended over the last few months of life. It is obvious that medical care is needed for sick people and sick people do tend to die. The problem is in the old and the infirm that get sick where even the best medical treatment cannot restore normal function. So the question in such patients becomes that what exactly is the purpose of intensive medical treatment.

The single most important development in curtailing ‘unnecessary’ medical interventions in the old and the very sick is the ‘advance directive’. Sick people can determine the extent of medical intervention they receive if they end up in a hospital. They can also have a living will to cover such issues. Such directives include instructions that among other ‘mechanical’ support systems a breathing machine or a heart support device should not be used under any circumstances. And of course the relatives are not allowed to override these instructions.

The second important aspect is a frank discussion between the doctors and the patient’s family about treatment options and the possibility of a functional recovery. Here it is important to stress that the patient if alert and mentally sound should be personally involved in the discussion and have the right to make a final determination. The patient’s direct involvement is absolutely necessary to avoid any blame placed on a particular care giver after the fact. And in case of extremely sick parents all important decisions must be made by mutual consultation.

There are some medical conditions where there is no chance of recovery. The two most common ones where the end does not always come suddenly but can be extended over many weeks and even months are incurable cancer, and severe and terminal neurological problems that leave a person incapable of independent life. The best that can be done then is to keep the person comfortable and pain free and wait for the inevitable end. For terminal cancer patients ‘hospice care’ is available in the US that allows supportive care without any major interventions.

The reason why I decided to discuss this unpleasant but necessary topic is that over the last year or so I have been a part of these problems as many of my close family members, friends and acquaintances wrestled with such situations. I realise that it is extremely difficult to decide that a beloved parent cannot be helped anymore and should be allowed to die in peace. But sometimes that is exactly what needs to be done. Personally, I am lucky that mother died after a very short illness while my father passed away peacefully in his sleep. Both of them had lived a reasonably long and comfortable life without suffering from any chronic, painful and debilitating disease.

Because of my medical specialty and surgical training, I have a pretty good idea when medical interventions are of little use. But it is difficult to extend that ‘knowledge’ to friends and family that do not have medical training. Through my observation over the years of people I know well and all of whom are extremely well educated I have realised that end of life decisions about loved ones are difficult for most people irrespective of their intellectual abilities. It is for this reason that the primary responsibility for these decisions should be placed upon individuals that are getting old and might have to encounter the scenarios I have described above.

If our elders have not made any such determinations then we should sit down and have a frank discussion with them while they are still capable of participating in such a discussion. In the US, end of life discussions with physicians are now encouraged and medical insurers (Medicare) will pay the doctors for these discussions like any other medical consultation. The single most important recommendation I have to make is that the parent or the sick member of the family if able should definitely be involved in such discussions. And in my opinion it is morally and medically wrong to hide important medical information from an adult loved one that is terminally ill.

Personally, I am slowly approaching the age when I will have to make some such determination about the extent of medical interventions I should receive if I become sick. However, right now, I am not willing to exclude any medical treatment if I suddenly develop a ‘catastrophic’ illness. But when my time comes, I would much rather die peacefully in my sleep.