Tales from the office


Although she’s in her late seventies and has memory problems, Sharon still recognizes that she enjoys the company of younger men. She has enough money to hire a full-time aide to assist her in all endeavors. And she always chooses handsome and educated men in their early thirties. I’ve met three of them so far. They stay around about two years and then eventually move on to other employment.

Originally, Sharon’s man-servants simply helped with manual labor. Now, with her declining memory, they serve as schedulers, organizers, and advisors. And as her health declines, their assistance seems to play a more salubrious role. For example, she wasn’t always a fan of taking her medicine. But now, her aide reminds and encourages (forces?) her to take her medicine. As a result her blood pressure and cholesterol are better-controlled than ever. I’d like to think that’s a good thing.

Sharon also suffers from seizures caused by falls from horses during her show-jumping days. Over time, the seizures have worsened. She takes strong antiepileptic medicines to control the episodes. In addition to the seizures, and due to the accrued brain injuries, she has lately been developing mild dementia (memory loss).

But, like most humans, she still remembers her grievances. During her last appointment in my office, in the presence of Scott, her latest aide, she informed me, to her chagrin, that she had stopped drinking. The reason: Scott had hidden all her alcohol and refused to allow her to buy more. As a cultured society woman, Sharon traditionally drank wine with lunch and dinner. Plus, she had one cocktail per night. For the last three months, she hadn’t consumed a drop of alcohol. She agreed that her mind was less cloudy, that she had more energy, and that her seizures were less frequent. But she still wanted to drink.

Control. That’s what so often what I want to exercise over my patients. I would love to control their lives. As a doctor, I’m taught research-based science that seems to show what therapies would improve a person’s life. I’d love to be able to force a patient to take a certain medicine. And I get so frustrated when patients suffer from a negative outcome that might have been prevented had they followed medical advice.

But I try to remind myself that there really are things greater than health. And one of them is probably autonomy. The freedom to make one’s own decisions (even perverse decisions) often gives more joy than the negated positive outcome. It reminds me of a patient I have whose husband died of lung cancer. She says that if she could live her life all over again, she wouldn’t have continuously nagged her husband to stop smoking but would have savored the moments when a cigarette made him happy. Is she right?

So I felt a bit of a dilemma with Sharon’s case. On the one hand, it’s clear that taking away her autonomy to drink was paternalistic and against her wishes. But, on the other hand, with her mental decline, I wasn’t totally sure that she understood the repercussions of drinking. Was it just a habit to have her drinks? If she stopped, would her quality of life diminish (due to ending her drinking rituals) or would it improve (due to stronger faculties)? And at what point can her aide—hired ostensibly to protect her welfare—make executive decisions for her overall “good”? Could he conscientiously decline to buy alcohol because he knows it might hasten her decline? Does she have the strength to fire him and find a more permissive assistant?

I made up my mind about the “correct” advice I’d give. I educated Sharon about the negative effects of alcohol on her health and encouraged her to quit. But then I instructed her aide that it would be inappropriate to oppose her request to drink, unless the time came that she was truly incompetent to make a decision (and even then it’s probably ethical to give her alcohol). I left the visit feeling comfortable with my advice. But I admit it’s nauseatingly easy for me to walk away patting myself on the back for my ethical pedantry. My role is minimal. It’s really the patients and their surrounding caregivers who have to deal with the daily tug of war deciding how to support each other as everyone’s health inevitably declines.

7 responses to “Tales from the office”

  1. cedric — once again your clinical anecdote has had me thinking all day.


  2. Dave says:

    Likewise. It’s impossible for an outsider to say what’s best for Sharon at this point, I think, and your decision to educate her and emphasize her autonomy to her aide was an admirable one.

    On a somewhat related note, what’s your position on making heroin freely available to anyone over 75?

  3. W2 says:

    terrrrrrriiiiffffffffffic post, as usual, good doctor. How do you think the desire for control over patients translates to a doctor’s control over him or herself? I’m thinking of extreme examples: the anesthesiologist who became a drug addict, the surgeon who smokes. Is there a percentage of the doctor population (greater than the percentage in the average population) who abuses themselves because they can’t control their patients’ lives?

  4. Cedric Cedarbrook, MD says:

    BW–Love ya.
    Dave–I really haven’t given much thought to free heroin for the geriatric set. I’m not sure if it’s been scientifically studied yet. I guess I’ll reserve judgement for now.
    W2–I am certainly not an expert on physician substance abuse. I googled a 1992 article from the New England Journal of Medicine which showed that compared to the general population, physicians used less tobacco, marijuana, cocaine, and heroin, and more alcohol and prescription drugs. I don’t know much about other studies before or since. And I can’t speculate on the causes behind the substance use. My lack of control over my patients often frustrates me, but I can’t say I’ve ever been tempted to use drugs to cope. But some doctors might.

  5. Stephanie Wells says:

    Well, I can say that I lived in a graduate dorm for a year while getting my master’s, and many of the other dorm residents were med students–and I never saw so much recklessly over-the-top drinking and drug use in my life, not even in the SF rock scene.

    As for patients who have chronic conditions, I sort of have to advocate giving them whatever they want to make their lives more comfortable and enjoyable, even if it may exacerbate the condition (as long as they’re fit to make that choice themselves).

    As for heroin for senior citizens: no more outrageous than medical marijuana–seems like a no-brainer to me.

  6. annie says:

    “The freedom to make one’s own decisions (even perverse decisions) often gives more joy than the negated positive outcome.”

    Loved this line–what it says about human nature and your role in the middle of it. Another sensitive post about your job and the people you see. Thanks.

  7. Stella says:

    I loved this. It’s so frustrating that while humans believe in their rational selves, we constantly make self-destructive choices. I wish I had wine at lunch and dinner plus a cocktail each day.