Medical Tests and Advance Directives

The May 25 post on the New Old Age blog, http://newoldage.blogs.nytimes.com/, discusses the distressing topic of unnecessary diagnostic medical procedures for seniors.  This particular post is focused on the overuse of screening colonoscopies for elderly adults, but it includes links to other articles describing aggressive blood-sugar screening and the ordering of frightening and invasive mammograms for women with severe dementia. 

If ordered by a physician, most of these tests are covered by Medicare, with little or no co-pay.  This is not say that they are free, as the  costs that are absorbed by Medicare, private insurance companies and/or health care providers are passed along to the rest of us one way or another.

For very elderly or demented seniors, there are other, more personal costs as well.  These tests can be uncomfortable to downright painful.  Some require sedation, which can further increase confusion for hours and days afterwards.  The patient’s routine is disrupted, which can be further exacerbated by wait times and the requirement for fasting or other pre-test procedures.  Finally, there is the assault on the patient’s dignity by a stranger who is requiring the patient to disrobe and endure unwanted touching.

I certainly recognize that these tests can be extremely valuable.  I’m sure everyone knows at least 1 person whose life was literally saved because his cancer was discovered early through diagnostic screening.  However, as noted in the articles that are linked to the New Old Age post,  cancers that are detected through diagnostic screening only (in other words, there are no other symptoms) after age 80 tend to grow so slowly so that, most often, the cause of that person’s death is something other than the cancer. 

These tests makes even less sense when an individual has made it clear in her Living Will or other Advance Directives that she would refuse treatment for the disease once it is discovered.  When that’s the case, logic would suggest that the person would refuse an invasive test to find the disease in the first place.   

Since health care providers have not,  historically, drawn the conclusion, individuals may want to consider using specific language in these documents to make their wishes as clear as possible.  For example, if you are expressing the desire that you not be subjected to surgery or any treatment that would only extend your life if you are suffering from dementia or are otherwise unable to express your wishes, you might consider specifically addiing that you also do not wish to be subjected to the diagnostic tests. 

The best way to avoid such tests is to have frank discussions with the agent on your medical power of attorney and your primary care physician about your wishes in this regard.  As is the case with all advance directives and end-of-life decisions, the more that you plan ahead, the greater control you will retain.

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