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Too Late To Operate? Surgery Near End Of Life Is Common, Costly

NPR

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came she wanted to die a natural death, Stanich told her daughter, and she signed a "do not resuscitate" directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock to her heart if it started beating irregularly.

At the time, Stanich didn't fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw the defibrillator protruding from Stanich's thin chest. It was the first time a doctor clearly explained what the defibrillator would mean for Stanich, said Giaquinto, who accompanied her mother on both hospital trips.

To Stanich's horror, the ER doctor explained that the device wouldn't allow Stanich to slip away painlessly. Instead, the defibrillator would give her a jolt "so strong that it will knock her across the room," Giaquinto said.

Surgery like Stanich's defibrillator implantation has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergoes an operation in the year before death, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital a week after her defibrillator was implanted.

"We have a culture that believes in very aggressive care," said Redberg, who specializes in heart disease in women at the University of California, San Francisco. "We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most."

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