FEATURE STORY

Empathy for the Elderly

An MU Physician Provides Care and Compassion for Elders at Life’s End

Note: Story by Alan Bavley and illustration by Gerard Dubois were published originally in the spring 2003 issue of Illumination, a magazine that showcases research, scholarship and creative achievement at the University of Missouri-Columbia.

Just over a year ago, David Mehr got an earful from a passenger sitting next to him on a flight home from Amsterdam. It was all about the hard time that his seatmate’s family was having dealing with a doctor who had been caring for his aged mother.

While the passenger bent his ear, Mehr, an associate professor of family and community medicine at MU, listened and sympathized. Mehr has been studying and caring for elderly patients for the better part of two decades. During that time he’s developed some strong opinions about the inadequate way some doctors handle elder care, particularly the care of seniors who are dying.

“I think communication around these issues leaves a lot to be desired,” Mehr says. Too often doctors don’t give families enough information to make informed decisions about how a spouse or parent should be treated during their final days, he says. Families are left to agonize over whether their loved one is getting too little, or too much, in the way of end-of-life intervention.

“Doctors should express their opinions more, make recommendations,” Mehr says. “I think it’s cruel not to recommend. It’s cruel to ask families to decide whether to do something that may result in the death of a loved one. We shouldn’t do that without giving them a compass.”

David Mehr

Mehr, 53, has long helped families find their emotional bearings while at the same time contributing important original research on some of the most common causes of death among elderly nursing home residents — pneumonia and other lower respiratory tract illnesses. His work has led to the development of new guidelines that allow doctors to more accurately identify which nursing home residents can be treated safely without hospitalization, and which are least likely to survive their illnesses.

This study and other related research has led Mehr to examine more broadly the kinds of care nursing home patients ought to be receiving as they near death.

“That’s the fundamental question in all of this,” Mehr says. “To what end is treatment? How long will a patient live, and with what quality of life after treatment?” Ask Mehr about his research and the needs of the elderly and his voice becomes animated, his bespectacled eyes gleam. His concern for his patients and their families is clearly evident. Mehr entered the field of geriatrics in the early 1980s, when few physicians focused on the special medical needs of the elderly.

While Mehr was in private practice in Columbia, he was approached by Stan Ingman, a sociologist with an interest in the elderly. Ingman, who was an MU faculty member at the time, recruited Mehr to help develop a curriculum on geriatrics.

To learn about this new subject, Mehr took on nursing home patients. Two of his first three patients had serious undiagnosed problems — one had an ulcer and depression; the second had severe confusion — which he was able to treat successfully. Mehr saw that this population of patients needed him. “There was this huge group of relatively neglected people I could make a difference with,” he says.

Making a difference has long been a key motivation for this California child of the 1960s. Mehr grew up in San Jose, Calif., during its pre-Silicon Valley days — a time when fruit orchards and canneries still outnumbered the subdivisions. He attended the University of California-Santa Cruz, at the time something of a hippie outpost, from which he traveled into Mexico and Central America. During his sojourn in the region, he noted the pervasive illnesses that afflicted many of the people he met. Mehr arrived home convinced that he wanted to become a doctor. “It was the era. I felt I needed to do something socially useful,’’ he says.

It was also an era of rebellion. So when Mehr told his father, an optometrist, and his mother, a psychologist, that he was considering medicine, they were careful not to seem too excited. “They were thrilled but didn’t want to act too interested,” Mehr recalled. “They thought that would be the kiss of death for the idea. They were probably right.”

Mehr attended medical school at the University of California-San Francisco and then migrated east to MU for his residency in family medicine. He went into private practice in Columbia in 1979 and eventually had about 80 nursing home patients in his care.

For the most part, Mehr enjoyed his work. But after a while, he admits he felt a bit oppressed by the business side of medicine. Then, in the mid-1980s, Medicare froze physician fees, and Mehr found himself at a distinct disadvantage: “I probably had the least expensive office visit in town, and now I was stuck with it. It got to be depressing to be working harder and not making more money.”

Mehr left Columbia for the University of Michigan, where he studied geriatric medicine and received a master’s degree in clinical research design. He spent two years on the Michigan faculty and then returned to Columbia to join the MU School of Medicine in 1992. Early on in his care of elderly nursing home patients, Mehr had recognized that lower respiratory infections and pneumonia were a major cause of illness that had never been studied adequately.

“Lower respiratory infections, predominantly pneumonia, were a common problem that I was diagnosing on a regular basis. We didn’t know how to treat them. There was no good information,” he says. The standard recommendation at that time was to transfer all pneumonia cases from nursing homes to the hospital.

“I knew in community practice a lot of nursing home patients were never sent to the hospital,” says Mehr. “There was this huge disconnect.” Even when patients got to the hospital, there was no good information on how to treat them. Treatment protocols were needed, but an even more fundamental need was tools to judge how sick these patients were.

While at Michigan he thought about this problem, collected some data and published his first paper.

“From the beginning, I recognized that clinicians thought about pneumonia, but the diagnosis was often not precise,” Mehr says. “That’s why I used the broader focus to be more consistent with what physicians deal with in practice. That is one of the things I think distinguishes my research and that of other family medicine colleagues.”

He returned to Missouri and continued this work, expanding its scope to include other lower respiratory tract infections (LRI) such as bronchitis along with pneumonia. His research culminated in the Missouri LRI Study, a prospective examination of more than a thousand residents in 36 nursing homes in central Missouri and the St. Louis area. The study ran for more than four years and produced a wealth of data.

Mehr and other researchers at MU, Washington University and Boston University used the information they had collected to identify eight varied measures, such as body mass index, mood and pulse, for predicting the odds that a nursing home resident diagnosed with a lower respiratory tract infection would still be alive 30 days later. The results were published in the Journal of the American Medical Association in November 2001.

This predictive tool still needs to be validated by more extensive testing in other parts of the country. But it could prove useful for keeping nursing home residents who are at low risk of dying out of the hospital.

“Pneumonia is the leading cause of hospitalization of nursing home residents, and we hope to decrease that number,” Mehr says.

Experts already are anticipating that many doctors will gladly adopt Mehr’s criteria for assessing pneumonia cases. “Managing pneumonia in the nursing home is a significant challenge for physicians,” says Gregg Warshaw, professor of geriatric and family medicine at the University of Cincinnati.

“Dr. Mehr’s research has provided physicians with criteria that help us to decide when it is appropriate to treat pneumonia in the nursing home or when hospitalization must be considered,” Warshaw says. “These criteria will become widely used by physicians and will reduce unnecessary hospitalizations and improve patient care.”

The Missouri LRI Study has yielded other findings as well, such as easier ways for doctors to diagnose pneumonia in nursing home patients. While working on the Missouri study, Mehr learned that researchers in the Netherlands had been doing similar work at the same time. Mehr and the Dutch researchers shared information and decided to collaborate on a study comparing how nursing home patients with lower respiratory tract infections were treated in the two countries.

Mehr spent a year on sabbatical in Amsterdam working on the project. What he found there raised challenging questions about how patients should be treated at the end of life. Nursing home residents in the Netherlands who were more impaired by dementia and who had more severe LRIs were more likely to receive just palliative, or comfort, care — not treatment with antibiotics. About 90 percent of those treated this way died within 30 days.

In the United States, by contrast, it was generally the sicker nursing home residents who were more likely to receive antibiotics: Among such patients with severe dementia, about 35 percent died within the same 30-day time frame.

Basic differences in the way doctors, and society at large, in the United States and the Netherlands viewed issues of medical ethics helped account for the great differences in how patients were treated in the two countries, Mehr says. Questions of medical futility, whether further treatment would significantly extend a patient’s life, played a more significant role in doctors’ treatment decisions in the Netherlands than in the United States.

“They’re more willing in the Netherlands to say, ‘We’ve done enough. Let nature take its course,’” Mehr says. “In the United States, doctors would be worried about being sued.” U.S. nursing homes also were more likely to automatically send sick patients to the hospital. “You hospitalize first and ask questions later. If you don’t do it that way, it’s a lot more work.”

In the Netherlands, aggressive care aimed at extending life often wasn’t taken. If a patient with severe dementia was expected to die in three to six months, medical care would often be considered futile and would be withheld. “That’s not at all the same sense in the United States. We tend to regard futile treatment in a very short context,” he says, adding somewhat facetiously, “In the U.S., medical futility means they’re going to die in an hour anyway.”

Public attitudes toward end-of-life treatment in the Netherlands also diverged from what would be expected in the United States. Mehr recalls being present when a Dutch doctor called in the family of a nursing home patient who had advanced dementia. The woman had developed pneumonia and the doctor was recommending palliative care. “The family said they would have asked doctors to euthanize her years ago if they could have. Euthanasia is allowed in the Netherlands for patients who are [mentally] incompetent,” Mehr says. “That’s unquestionably a different social climate.”

Mehr says he doesn’t necessarily advocate the Dutch way of treating nursing home patients, but their approach does raise some provocative issues that people in this country ought to consider. In the United States, fully 60 percent of nursing home residents suffer from dementia, for example. When patients with dementia in its most severe forms develop either pneumonia or a lower respiratory infection, the prognosis is particularly grim: Studies indicate that within one year more than half will be dead. “Should lower respiratory infections and severe dementia be indications for palliative care?" Mehr asks. “At the very least, we need to be asking these questions. Is it time to change the focus of care?”

Mehr wants to look at how families and physicians make decisions about end-of-life care: Who starts the discussions? Is it physicians or family members? Mehr anticipates that any survey of doctors and families will find that there are systemic barriers to good discussions of these issues. Families may not ask questions because they don’t think they are supposed to. Doctors may not bring up certain issues because they lead to difficult discussions. Besides, they don’t get paid for dealing with such issues. “We don’t provide people the kind of context they need for making decisions,” he says.

Mehr’s research hasn’t been limited to the way physicians treat nursing home patients; he also has turned his attention toward ways nursing homes can improve. One of his studies examined six case histories of problems that nursing homes had in evaluating and treating severe illnesses. He found a common theme in communication breakdowns among staff, doctors and residents.

A nurse at one home, for instance, didn’t want to deal with a particular resident because, she claimed, he had “grabbed her.” And some physicians’ offices apparently had a policy of only accepting faxes, and not phone calls, from nursing homes. But after long experience caring for the residents of nursing homes, Mehr isn’t about to condemn these facilities out of hand.

“Some of the criticism is justified, but there’s a huge variation among nursing homes. The general impression that there are nursing homes that are all good or all bad is hard to verify from the data,” Mehr says. “We’re a long way from assessing quality completely. Quality is multidimensional. A nursing home that is good at minimizing falls may not be providing a stimulating environment for residents. It may not be possible to be good on all dimensions.”

While his professional life has focused on the elderly, in his personal life, Mehr has managed to stay on the young side of things. He runs several times a week. He recently took up yoga. And Mehr is a newlywed. Both he and his wife, Ann, an elementary school art teacher, have been married before.

“We think we finally found the right partners,” he says with a smile. Mehr says he’s been inspired by some of his patients who have maintained a youthful perspective late in their lives. “I’m very much a believer that you’re as old as you feel. My approach is to appreciate the perspective time and experience bring.”

Mehr doesn’t consider people physiologically old until they are 75 or even 80. “Sixty-five’s not old as far as I’m concerned. And I don’t say that just because I’m 53. I’ve been saying that for quite a few years,’’ he says. “You try to live life fully. You’re only going to be old when you stop learning about new things. I think that’s as true at 90 as at 50.”

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Last Update: November 15, 2007