Death or taxes?

May 4, 2007

The author saw the logic behind this unsettling dilemma, but that didn't make it an easier decision. 2006 DOCTORS' WRITING CONTEST -GRAND PRIZE WINNER

Shortly after retiring from my full-time faculty job at the local teaching hospital, I took a part-time position with hospice, evaluating patients in their homes and in nursing homes. Having been a clinical oncologist for many years, I was surprised and unnerved when I ran into a case that challenged me in ways I've never been challenged before.

I went to see a woman in her 90s who had been living for years at one of those nursing homes favored by the well-to-do. It was part of a multilevel retirement community where older people went to live independently, then, when they needed to, moved to the assisted-living or the skilled-nursing unit. The patient had had a major stroke two weeks earlier. After a few days in the hospital, it was clear that she wasn't going to get better, so her family had decided to bring her back to the skilled-nursing unit and let her die peacefully under hospice care.

It was late December, and Christmas decorations were everywhere. Jolly carols came from a CD player at the nurses' station as the hospice nurse and I reviewed the patient's chart. Across the hallway, a cluster of patients in wheelchairs sat in front of a television watching, or not watching, It's A Wonderful Life.

"Tell me about your mother," I began.

The story unfolded. The patient, a widow, had been at the facility for several years. Her mind had gradually failed, and she needed more and more help getting dressed and out of bed. Otherwise, she had been reasonably comfortable and cheerful until her stroke, which paralyzed her right side and left her in a semicoma that the doctors said wouldn't resolve. She hadn't been able to eat or drink anything and, prior to her discharge from the hospital, the family had decided against a feeding tube.

The old woman didn't respond when I called her name or touched her, but she was in no acute distress. She was mildly dehydrated and didn't move her right arm or leg, but her blood pressure was normal and her lungs were clear. I assured the daughters that their mother was comfortable and that we would do whatever was necessary to keep her from suffering.

Once we were out of the room, I asked the daughters if they had any questions or concerns.

The older daughter thanked me for my visit and then asked, "Doctor, how long do you think Mother might live?"

"That's always difficult to say, but your mother hasn't had food or liquids in several days, and usually people who stop eating and drinking die within two weeks. So I would say she isn't likely to live more than a few days."

"I see," she said. Then, after a brief pause: "Doctor, I know this might sound crass, but we had a meeting with Mother's lawyer yesterday and he said it would be much better if Mother died after the first of the year."

"Is that right?" I said, wondering for a few seconds what she might mean. Then it hit me. The estate-tax laws had changed, and next year the amount exempted from taxes would be much higher than this year. For a large estate this would mean a reduction in estate taxes of more than $100,000.

"I don't think your mother will live until the end of the year," I said.

"Is that because she isn't eating and drinking?"

"Yes. She might live longer if we were to hydrate her, though she could still die of pneumonia or some other complication."

"Suppose we were to decide to hydrate her? What would that involve?"