Dr. Louis M. Profeta, and emergency physician practicing in Indianapolis has written a compelling article “I Know You Love Me- Now Let Me Die”  
This is a great blog post about end of life.  I totally agree that we have “medicalized” end of life—it gets death out of the home, which certainly sanitizes it. In the old days, the body would be displayed in the parlor for the neighbors to come to the house to visit for the wake.  I think that particularly for an elder with dementia the first thing to ask is, how will that improve the quality of life now, not possibly preventing a big stroke in the future (endarterectomy).  I would say for elders with dementia, they often do not understand the hospital, nor what procedures are being performed such as having to be restrained by tying down their arms, or chemical restraint with medications like Ativan and Haldol. The question that must be asked is how does that improve quality of life, if they are scared and uncomfortable?
When meeting a family, the first thing I ask is- “What makes life worth living”” for this loved one. Most care can be in the elders’ home, including X-rays, blood tests, and often IV fluids.  I do send elders into the hospital for fractures to stabilize and decrease pain with repair or splinting.  Then, when the elder declines to the point that they qualify for hospice, we refer.  We remain as the following doctor most of the time, since we are always on call and are familiar with the patient’s case, and can be the continuity for a supportive organization. However, by necessity, hospice has nurses cover in shifts that may not be familiar with the elder.  For an elder with dementia the best way to end one’s days is to stay in a familiar place, with family and caregivers they know and be free of pain.
What do you think?
Elizabeth Landsverk, M.D.