Death Is Not a Question of If, but When, Where and How

Excerpt from Letter to the Editor published in

Clinical Geriatrics. 2012;20 9):8-9

Death Is Not a Question of “If”

….. There is an area, however, that you did not bring up in your review of risks, benefits, and alternatives—death is not a choice of “if.” In our modern medical world, death is much more a choice about when, where, and how. This essential truth seems to escape us as physicians. An inevitable effect of coronary artery bypass graft surgery, pacemakers, implanted defibrillators, and other aggressive treatment is that many of us live long enough to live with and die from advanced dementia or live with other chronic conditions, such as significant daily pain from arthritis.

The 80-year-old woman described in your article developed delirium, a harbinger of dementia. Whether unresolved delirium leads to incident dementia or whether undetected cognitive impairments are worsened by the underlying medical conditions that cause the delirium leading to a new diagnosis of dementia, there is definitely a relationship between the two syndromes. Although I was not there to speak to the patient’s family, it sounds like they chose to honor her independence by not intervening, by letting nature take its course, and pursuing comfort measures for her in her final days….

I have seen far too many patients who tell me that they regret the medical choices they made in the past because they did not appreciate the difficulty of living with physical and cognitive disabilities. They did not anticipate that there would be any negative sequelae, and the medical professionals no longer involved in their lives did not forewarn them. These are not people suffering from major depressive disorder and inappropriate guilt, these are average men and women who anticipated getting older without deficits or difficulties and just dying in their sleep before developing chronic disease.

I disagree with you that her family chose to do nothing. The family chose to honor her independence and to let nature take its course. This is not nothing. This is a brave choice. This is a choice that some, though not all, would make if they were able to see into the future, if they were reminded that it is not if  we die, but when, where, and how.

Maureen C. Nash, MD

About mcnash

Maureen C. Nash, M.D., F.A.P.A. is board certified in both psychiatry and internal medicine and serves as the Medical Director of the Tuality Center for Geriatric Psychiatry (TCGP) at Tuality Forest Grove Hospital. TCGP is a dedicated acute inpatient geriatric psychiatry unit in Oregon and serves as a referral center for all of Oregon and southwest Washington. She is the Chair of the American Association for Geriatric Psychiatry (AAGP) Clinical Practice Committee, serves on the AAGP Board of Directors and has served on the AAGP Education and Research Committees. With her involvement in these national efforts, Dr. Nash is working to help promote the mental health and well being of older people and improve the care of those with late-life mental disorders. She has clinical appointments at Oregon Health and Sciences University Psychiatry Department and Pacific University Physicians Assistant Program where she mentors geriatric psychiatry fellows and PA students. She has received a number of awards including being recognized as a Top Doctor by Portland Monthly and earned a number of awards on Health Tap, a digital platform to improve community access to reliable medical information. Dr. Nash has specific interests in improving the access to mental health care for older adults, improving the quality of care given to those suffering from dementia and improving the ability to accurately assess capacity in older adults. She is a sought after public speaker/expert and has been invited to give presentations to many organizations including the American Psychiatric Association, AAGP, National Association of Guardians, Alaska State Guardianship Association, Oregon Alzheimer’s Association, Oregon Gerontological Association, Parkinson’s Resources of Oregon, National Association of Women Judges, Oregon Bar Association Elder Law Section…. She served on the State Plan for Alzheimer's Disease in Oregon (SPADO) Task Force, leading the Medical/Research subcommittee and has served on a number of workgroups for the Oregon legislature on issues involving older adults, dementia and mental illness. Prior to joining the Tuality Center for Geriatric Psychiatry in 2005, Dr. Nash served as Medical Director of the Colby Center for Psychiatry (an inpatient psychiatric unit for older adults) at the Adirondack Medical Center in Saranac Lake, N.Y. She earned her medical degree at the University of Kansas School of Medicine. She went on to complete her residency at the combined internal medicine/psychiatry residency program at Dartmouth Hitchcock Medical Center in Lebanon, N.H., where she also served as chief resident. She was an instructor in psychiatry at Dartmouth Medical School in Hanover, N.H. Prior to her medical career she was a computer engineer specializing in hardware/software integration in a research setting.
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