Virginia Eldridge can’t walk or talk, and she can’t feed herself. Locked in the permafrost of Alzheimer’s disease, she hasn’t recognized any family member in years. She is 99 years old.

Is she at the end of her life? For a while, her doctors and family thought so. They moved her into hospice, where, it was assumed, she would die within six months.

That was two-and-a-half years ago. Recently, her family had to move her out of hospice care because she didn’t show any signs of dying.

Her advanced Alzheimer’s is considered stabilized. Her caregivers spoon out a puree and she swallows it. While she doesn’t have a life, she keeps on living.

This is one of the dilemmas of American life. Through a triumph of will, organization, medical technology, and ethics, frail elderly and chronically ill people in the United States are being kept alive far beyond the point at which they would have succumbed in earlier generations. Dialysis, intensive care units, organ transplantation, cardiovascular procedures, and medications are indefinitely extending the lives of very sick people who are never going to get well.

Only in America, it seems, will doctors, hospitals, and families keep the frail elderly alive at any cost—in Mrs. Eldridge’s case, $135,000 a year.

As the population ages, this all-measures-at-any-cost regimen holds out the prospect of effectively bankrupting the United States, and it’s not just Medicare that’s financially unsustainable at this rate of expenditure. Seniors and their families are being financially wiped out by copayments, deductibles and uncovered expenses involved in prolonged end-of-life care, not to speak of the emotional toll.

“The single greatest pressure on health care,” wrote journalist Michael Wolff last year in a harrowing account in New York Magazine of his mother’s dementia, “is the disproportionate resources devoted to the elderly, to not just the old, but to the old old, and yet no one says what all old children of old parents know: This is not just wrongheaded but steals the life from everyone involved.”

About one quarter of Medicare spending occurs in the last year of life. Policymakers and medical ethicists are asking whether this can be justified, given the poor quality of life that many of these patients experience in the months leading up to a certain death. To some observers, cutting back on end-of-life care seems like the obvious place to start if we want to reduce Medicare expenditures per person.

In reality it’s not that simple.

“Did you ever hear a doctor say to her patient, `Mrs. Jones, it says here your last day of life will be Oct. 2, 2013. So we shouldn’t spend the money on your chemotherapy,’” said Richard Hirth, Ph.D., professor in the Department of Health Management and Policy at the University of Michigan. “We have these statistics retrospectively, but you have to make the medical decision prospectively.”

To fix this, Hirth added that we either need to determine in advance when someone will die, which is nearly impossible, or do something to change their treatment, which is even harder.

“Physicians I talk to say it’s harder to deal with end of life today than 40 years ago,” said Daniel Callahan, founder of The Hastings Center, the first bioethics think-tank, located in Hastings-on-Hudson, N.Y. Medical technologies have made walking the line less and less.

“It’s very hard these days to say when somebody is actually dying,” Callahan said. “Physicians can always find a way to give you another day, another week or another month of life.”

In his book, “Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System,” Callahan argues that the United States is unique in its emphasis on medical research and development of new technologies. Public opinion polls demonstrate that Americans place a greater value on these life-extending inventions than people elsewhere.

Medical professionals in other developed countries are trained in technology, “but Americans are obsessed with it,” Callahan said in an interview with The Medicare NewsGroup. And the way the U.S. health care system is set up, the more technology you use, “the more money you make.”

Even patients with advance directives, which are supposed to restrict what the medical system can do to and for them, are talked into procedures or measures of last resort. “There’s always one last surgery or trial,” Callahan said. “It’s very seductive.” And the national furor around “death panels,” fanned by Sarah Palin and others, effectively shut down any serious discussion about how families and doctors should think about addressing the care of the frail elderly.

It doesn’t necessarily work this way in other countries. Callahan, who is the son-in-law of Virginia Eldridge, has spent a lifetime exploring what goes on in Europe.

“They don’t want to talk about rationing any more than they do here,” he said.

That doesn’t mean it doesn’t happen, quietly and covertly. In other countries, doctors and medical professionals still have the authority and paternalistic attitude that has seeped away from medicine in the United States.

Doctors make a private decision about what they think will be good for their patient, and tell the family that there is nothing to be done. “It might be a flat-out lie, or it might be just not worth the cost,” Callahan said.

Many European countries operate their medical systems and hospitals on a fixed annual government budget. If too much is spent on one individual or a class of patients, the health care system will run out of money before the end of the year, and so doctors and others in the medical profession would be forced to curtail services or institute rationing.

In the 1960s and 1970s, it was well known that the British rationed medical care, especially kidney dialysis at the end of life. People older than 55 simply didn’t get dialysis.

“It was not a written rule, it was simply understood…an unspoken gentlemen’s agreement,” Callahan said. The reason was, “If you do a lot of dialysis, you will ruin your budget.” When the public caught on, that practice seemed to disappear.

Today in Britain, quiet decisions are still being made every day to conserve medical resources. “Doctors discuss it among themselves. ‘Let’s not put this person in the ICU.’ They don’t consult the family, they just do it,” Callahan said.

That attitude wouldn’t fly in the United States, where patients and their families expect to participate in health care decision-making. Furthermore, strong religious beliefs may color how a person or family responds at the end of life.

Christians should be “footloose and fancy free” because of their belief in the resurrection, said Philip Boyle, vice president for mission and ethics at Catholic Health East in Philadelphia. Theologically considered, “we don’t have to put all the stock in human life; there’s more to it.”

“Obviously, people don’t believe it well enough,” he said, “or they’re not convinced of the resurrection.”

Other religions don’t regard the transition into nothingness as an evil, Boyle said. “The idea that death would come along is not an insult to a Buddhist in the way that for a Christian it would be.” There is nothing in the mainstream U.S. religious traditions that tells people to “hang on to your dying day, use everything you can to stay alive,” he added in an interview.

Joanne Lynn, M.D., a national expert on care of the elderly, wrote, “People find little guidance when they look to our ancient texts for comfort and advice on how to live while walking a tightrope of serious illness and frailty, propped up by modern medicine.” A patient once told her, “No one in the Bible died like this.”

In the 1970s and 1980s, in response to increasing medical interventions on frail, dying people, a movement arose to encourage patients to sign advance directives, which guide caregivers as to the patient’s wishes at the end of life.

Advance directives, or ADs, have not worked out as anticipated, however. “Many people never complete them, or they complete them and then there is a failure of communication” with doctors and family members, so the patient’s intentions are ignored at the end, said the Rev. David McCurdy, director of organizational ethics at Advocate Health Care in Chicago.

Even with an AD, “people have to have the courage to make decisions that are difficult or painful,” McCurdy said. “People don’t want to talk about suffering and death. The document gets used as a legal document, where what it needs to be is a springboard for conversations.”

Sidney Callahan, 79, is Virginia Eldridge’s stepdaughter and Daniel Callahan’s wife. She is a retired professor of social psychology who spent her life thinking about the intersection of religious thought and culture.

She takes a much more pro-life approach than her husband. There is a value just in life itself, even among the very old, she argues. Despite all the pain and expense, “you want them to live.” It’s part of the national ethos, she thinks. “We are Americans. We want to overcome and relieve suffering. We want to make progress against terrible things in life. In that aspect, it’s good.

“It becomes maladaptive when you have a situation where what is needed is acceptance,” she said in an interview.

That’s why she admires the African-born caregivers who look after her stepmother. They are more accepting that this is a part of life. “They’re very kind. They even call the older people ‘Grandma’ and ‘Mom.’ They’re identifying them as part of a family and extended clan. I like that.”

Sometimes she wishes that her stepmother would peacefully die and not linger on in this half-life.

But last year when Mrs. Eldridge had the flu, she found that she had a completely opposite reaction, Callahan wrote on her blog. “As she labored with her oxygen tube I found myself frantically praying for her recovery. ‘No, please Mommy, keep breathing, don’t die’.“

Her mother pulled through. (MNG) original articles and Medicare Matters news summaries can be reprinted or republished with credit to the Medicare NewsGroup. To use our content, simply copy and paste text from the MNG website. Use of our content is done in compliance with our Terms and Conditions but does not extend to material from other sources that are subject to their copyright.