Love and frailty and an avalanche of missteps

A retired oncologist describes the unexpected death of his wife, Claudia, who spent 25 years as head of the geriatrics service of a major VA hospital. The couple drew comfort in their orchestration of a "good death"; nevertheless they understood that her death was hastened by a number of missteps. In the 2 months following a hip fracture, a chain of complications that required five surgical interventions led to massive hemorrhage from necrotizing esophagitis. Claudia lacked resilience to recover from a sequence of traumas sustainable by a younger person-but even the most experienced geriatrician might not have identified or even suspected her risk. Despite multiple well-controlled comorbidities Claudia was active and independent. She exercised daily and traveled extensively. She did not fit the profile of a frail or vulnerable person, according to assessing instruments in current use. According to the e-prognosis calculator, her mortality risk was 10% lower than that of women her age. It is not surprising, nor deplorable, that after Claudia developed mild dysphagia, a gastroenterologist put off an EGD, awaiting a cardiac consult. That delay, however, proved fatal. Had the procedure been performed as soon as possible, it would have revealed esophagitis caused by a hiatal hernia, signaling need for different medications and prompt treatment. This might have prevented the terminal hemorrhage. The first important lesson from this case is that for an older patient with multiple comorbidities, even under control, delayed treatment is treatment denied. Current evaluation instruments are unable to spot critical resilience reductions in functional seniors. Inadequate pain management, premature discharge after surgery, and poor communication also contributed to the death. The second important lesson is that older patients, even when they are medical doctors, would benefit from a trained advocate to help them navigate the medical system.