Dr. Emanuel’s 75 Plan

Posted by on Sep 30, 2014 in Education, End of Life, General Medicine | 8 comments

Dr. Emanuel’s 75 Plan

When teaching about life near dying, it is hard to achieve open conversation.  No matter what one says in a lecture hall or what brilliant writers publish on the terrible state of end-of-life care, change is painfully slow.  While we blame evasion by doctors of challenging conversations, failure by patients to plan or denial by families which blocks open communication, the real obstacle is a simple, basic reality.   We talk about death as a theoretical, philosophical and spiritual issue, we do not confront the fact that it applies to each one of us; that failure probably causes more suffering than any disease.

In his brilliant and sentinel essay, in The Atlantic, Why I hope to Die at 75, Dr. Ezekiel J. Emanuel has taken a hammer to that denial and strongly hit us over the head.  Clearly fed up the repetitive conversation dominating the end-of-life literature about the need to fix the sea of suffering which is poor terminal care, Dr. Emanuel has decided to frame the argument in a unique, powerful and personal way.  Instead of droning on about unnecessary pain, wasted resources and the vagaries of terminal chronic disease, he tells us exactly when and why he wishes to die.

Dr. Emanuel’s argument has three basic parts. First, life ends and we should accept that universal reality and plan for it.  Second, the last part of living is not always pretty.  Quit the opposite, it can be horrid. We lose mobility, mental acuity and our opportunities radically decline. Therefore, he proposes that those who value life and the life of loved ones, will plan for it.  Most importantly, Dr. Emanuel is saying, figure out what life means and build your future from there.

To make that empowering argument Dr Emanuel has offered himself as bait.  He picked a number, 75 years.  After that time he does not plan to fight to stay alive. This means that he will forgo both preventative and active medical care. While he does not plan to take hemlock, he also will not take ampicillin.  He explains in detail how that which is important to him in life will be complete.  He does not wish to live debilitated without those things he views as giving life quality and justification.  Therefore, at seven decades and five, he will accept death.

Dr. Emanuel has struck a deep cord.  The hailstorm of attacks about ageism, elitism, rationing, death panels, bizarre references to ObamaCare and a flood of personal attacks can only mean that his words are exactly on target.  Even though most writers agreed we have an immense problem with poor end-of-life treatment, he was attacked for being heartless, denying the potential of life and fostering a secret agenda to kill off the elderly.  Even those who support open discussion about palliative care and dying attacked him for saying too much; they feared his words would push backward the conversation.

No recent single essay or speech about the importance of personal planning and the limits of life has resulted in such a logarithmic increase in this vital conversation.  Bravo!   Wherever we each fall on this issue, clearly he has achieved the major goal of making us talk; that can only be good.  Still, I worry that in the confusion and talkback, we may miss his main message.

Much of the pure rage, which was directed at Dr. Emanuel’s words, focused on his personal choices and priorities.  Myriad examples were written to show that not everyone is demented at age 90 or that people can be happy even living in a nursing home.  Wonderful stories of life lived to the maximum at any age flooded the comments.  This misses the core point of the article. We may or may not agree with Dr. Emanuel’s personal priorities. That is irrelevant. The question he asks is what does life means to each of us and what we plan to do about it.

75 is not a measure of time. 75 is rather a statement of meaning and quality balanced with reality.  75 means life is precious, finite and different to each of us.  75 is the critical concept that if we do not each accept that life ends, and that it often ends badly, that if we do not, with eyes wide open, decide what is important to each of us, then it will be decided for us by biology, physiology, disease, doctors, insurance companies, friends, attorneys, strangers and the dystopia which is our healthcare system.

For Dr. Emanuel 75 means not being able highly mobile and creative.  For my patient Ken, 75 meant a spinal cord compression after which he demanded we pull the plug.  For octogenarian Karen, 75 means sitting in a wheelchair surrounded by laughing grandchildren, even if she cannot quite remember their names.  For Robert, 75 meant dying at age 34 from a benign stomach ulcer because he refused blood transfusions.  Lillian?  A bone marrow transplant with permanent nerve damage and blindness.   Cardiac patient Joe?  His third heart attack running a marathon.  Margaret, almost completely brain dead, was kept alive for months on machines because to her life meant a beating heart.

75 is the ultimate statement of personal freedom. Call it a 75 Plan.  Accept that your life will end.  Decide what is most precious about being alive and what you will sacrifice to hold on; try to figure out at what point simply breathing will not be enough. Understanding that this plan may change, share those ideas with those you love.  Then, smile, standup, stretch, greet the sunrise; get out there and live.

8 Comments

  1. I read that a while back – while his point, that you need to think about what it means to live a full life and what to do or not do to meet that goal is valid – I do think that the definition of what is “old” is a moving target. A grade schooler thinks 30. At 30 you think 50 or 60. At 60 suddenly it is 80… or whatever. It would be interesting to see, the closer he gets to 75, if he is in good physical shape, whether or not he slides that deadline towards an older age.

    My point is that perhaps it isn’t picking an age to cut off medical care, including preventative, as he is choosing to do (I have some relatives that didn’t really start to slow down until their mid 80’s and for others it was younger), rather perhaps define a state of existence beyond which you don’t want to do these things presuming you think his idea is a good one, and then implement it then.

  2. Let’s see how long we can go without saying Patient failure to . . .

  3. You thought the essay brilliant and sentinel. I thought it arrogant and
    condescending. This is a conversation that needs to take place early
    and often. Having the conversation with the feet on the desk, sucking
    on a beverage is such a great promotion!

  4. All of my grandparents lived past 95. One used a hand scythe and cut the brush and grass down for his ‘old’ neighbors that were in their 50s and 60s. He missed his brothers that died in their 70s and 80s. He missed co-workers that died in their 50s and 60s. He died in a hunting accident-pheasant hunting. He was 95.
    His wife died a few months after he passed. They were married when teenagers, He was a 14 year-old cowboy that saw a pretty 18 year old farm girl. He went there after the cattle were penned at the rail head, and asked her if he could go bird hunting. The third day, she was sitting behind him, as he rode off to town. She waxed the floors, a blizzard hit and she slipped and broke her hip. She died. She still went to the race track on public transport in her last summer.
    My other grandpa was killed on his 96th birthday by a drunk speeder. His wife was over a 100, and the car she was riding in was hit by a drunk. She could still touch her toes.
    I’m 72, and most of my doctors don’t know what to do with me. I was poisoned in trying to control cholesterol. It ruined my Achilles tendons. I had to go to PT and learn to walk and get my tendons treated.

    If you want old people to live long- quit poisoning them or expecting them to sit on the couch all day. Me I look at the treatment- I tell them -NO- politely. I’m not being poisoned again. I did have radiation for the cancer, but that was a simple non-complicated procedure. Medical people got mad when when I said that I’d rather die than have the recommended treatment, which included a year in a nursing home-Where’s the quality of life there.

    I don’t know if I’ll live to 75 or a 105, I have on my final directive to pull all tubes out after 3 days. Oh they told me and my family that I was crazy. Then they told my family that they are crazy, because my family backed me up.

    I had sort of hoped that I’d die with my boots on, while working a horse in the mountains or get shot–but my God wasn’t calling me. My brother sort of thought that he’d get shot or get lost in the eastern pacific while night diving. April 2015, We are going to visit each other, and I’m not flying on Malaysian airlines. So many people can’t understand the difference between acceptance and suicide.

    I understand quality of life—-So did my grandparents.

  5. Dr. Emanuel’s 75 plan organizes and thoroughly articulates the sentiments swirling in my own head over the past 7 years or so. Caregiving for elderly parents and in-laws has helped me arrive at the same conclusion as the one Dr. Emanuel holds. I truly appreciate the validation!

  6. You wrote:

    “Dr. Emanuel’s argument has three basic parts. First, life ends and we should accept that universal reality and plan for it. Second, the last part of living is not always pretty. Quit the opposite, it can be horrid. We lose mobility, mental acuity and our opportunities radically decline. Therefore, he proposes that those who value life and the life of loved ones, will plan for it. Most importantly, Dr. Emanuel is saying, figure out what life means and build your future from there.”

    No he isn’t! There is no “argument” or “proposal” here. The only time the author says the word “plan” is when writes: “Indeed, I plan to have my memorial service before I die.”

    This article is about medical advancements fostering the belief that a kind of immortality can be attained without trade-offs and consequences. It is about his personal choice to object to the prolongation of his own life at any and all costs because, in his opinion and experience, the trade-offs and consequences are not worth it. His (arbitrary, not fixed) selection of the age 75 he feels is a good point before the physical and/or mental failings (which he does not want to be remembered for) are statistically likely to set in. He feels that he would suffer less from the consequences of palliative treatment than a more active and invasive medical approach.

    Whether we plan for it or not, death is coming for us all. Sounds like a scary movie, doesn’t it? We can plan all we want but no amount of planning will ensure that our wishes will be carried out. Planned or not, we all simply hope that we will have a non-suffering end to our lives. Does the person who plans for every eventuality get better care? No. In fact, they may be more stressed at end of life BECAUSE their plans are not being carried out. Plans or no, we will all die. Families of those who have planned and families of those who have not will still rationalize away anything that cannot be easily explained.

    No one has the right to force any of us to do the things that they feel (but we don’t feel) should be done at end of life. They may have the power to do so but they will never have the right no matter what country you reside in or government you support. Should you be forced to “make up with your crazy Uncle Larry” if you don’t want to…no. Should you be forced to do or talk about anything you wouldn’t normally have done in your 40…50…60…70…or 80 years of previous life? No. Should you be forced to become a different person than you’ve been all your years because someone else (and likely a total stranger) thinks it is a good thing to do now? No. You are the one dying, not them. They can choose their own way in their own time but not force it on you. And especially when they are continuously espousing how “You’re the boss” and “You’re the one in charge.”

    Elisabeth Kübler-Ross felt this same way about death and dying and wrote about it as such. But today, just as with her writings and now Dr. Emanuel’s article, we take things and twist and warp them to mean what we want them to and not what was actually or originally intended.

    Did Dr. Emanuel really mean what he said about not influencing anyone towards his opinion? No. If that were true, he wouldn’t have written the article in the first place. Or, maybe he just likes to write articles that stir things up. You be the judge. What I read from Dr. Emanuel’s article was ‘this is what I think…whether my kids like it or not…maybe it will help you make decisions or maybe not…it’s all up to you.’

  7. And he’s also promoting hospice…albeit hospice early. Isn’t this what the hospice industry wants and has been promoting all along? Isn’t this what the hospice industry has been harassing doctors about (and belittling their skills for) for years now? Isn’t this what the hospice industry has been seeking in loosening the rules for patient entry into hospices’ services and if the government won’t loosen them they will do it themselves anyway?

  8. As always, a calm and reasoned evaluation of a raging controversy! Thanks for being so sensible. In your profession, especially, you certainly see a lot of unrealistic efforts to prolong life and the grief that causes.
    I think part of the issue is that so many people are afraid of dying, and they somehow cannot admit that it’s an integral part of life. However, Emanuel seems is a bit heavy handed in places – for example, his suggestion to refuse antibiotics for an infection.
    When I turned 50, I told my children that, from then on, if I ended up in the hospital, I wanted NO extreme measures. I drew up a living will, with the help of a lawyer, and made my eldest daughter the executor (the middle one would have disagreed with several of its terms). My body has been willed to the local medical center, so I don’t want it carved up a lot before I die.
    BUT, I’m now nearly 78 years old (next month), and I’m still living an active, happy, productive life. I’ve published two books since retirement and am revising the manuscript for a third. I’m certainly glad I didn’t give up at 75!
    Keep on telling it like it is. I see you’re now regularly listed in Kevin Pho’s MD today.

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