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Doctors are trained to do whatever they can to save a patient, even an elderly one, and that is an excellent thing. But that Hippocratic impulse has been subtly undermined by the rewards of fee-for-service medicine and by the threat of malpractice suits, which militate in favor of ordering the extra MRI or blood test or dialysis even for a patient who probably has only weeks to live. And so it was that when my father was rushed to the Mount Nittany Medical Center suffering from acute kidney failure in late January, the immediate impulse of the doctors in the emergency room was to try to revive him by rehydrating him. "That's how they're trained," my father's urologist, Dr. Charles Dalton, told me. Dalton is a terrific fee-for-service doctor who had impressed me with his Geisinger-like candor in the past. "But [rehydrating him] was probably the wrong thing to do," Dalton went on. "Renal failure is a good way to go. You just go to sleep. Your dad's kidneys are pretty much shot. You may revive him, but he'll be back here in a month, six weeks."
My next decision seemed obvious, but it was much tougher than removing Mom's feeding tube. This was Dad. He had always haunted my dreams, and now I had visions of the Mighty Malcolm rising from his hospital bed, screaming at me for trying to kill him. But that Malcolm had disappeared after Mom passed away in November, a few weeks after the meeting with Maxin. At the end, I had fed her several teaspoons of chocolate ice cream and said, "I love you, Mom." Her last words were "I love you too." An hour later she was gone.
The next morning, I told Dad that for the first time in 86 years, there was no Miriam. "Is it definite?" he asked, crushed. His will to live vanished. He pretty much stopped eating. I tried to revive his interest in food by having the nursing home serve him more of the things he loved to eat--salads, pancakes, a glass of sweet white wine with dinner. "You did that? That's amazing," he said of the wine. "I really appreciate what you're doing. You're a good son," he said for the first time in my life. I told him he had been a great dad. "I could have been better," he replied.
But he forgot to ask for the wine with dinner. And he often forgot to eat dinner. He slept through most days. And about eight weeks after Mom died, his kidneys failed and I faced a final decision. Anil Aleti was the Geisinger doctor on call at Mount Nittany, and he was every bit as forthright as Maxin and Devan. We could keep Dad going with intravenous hydration, and he might last a month--there was no question of inserting a feeding tube--or we could stop. I called my brother and told him that I'd decided to let Dad go. He agreed, as he had every step of the way.