Ms. Spanker,

As a physician with PD, I have more than a passing interest in the subject
you pose to Dennis Greene.

In general here in the States the process is similar to obtain a DNR order.
If a person is deemed to be incompetent by 2 physicians  or a psychologist
and a physician  a court hearing is held to determine competence to handle
his own affairs.  Then determination what happens from  there is in the
hands of the court appointed guardian.  If there is a document called a
power of attorney for health care affairs then I believe the time can be
shortened and it can be invoked  by 2 doctors saying that the person is
disabled who are not the attending physicians.  This allows a patient to
designate who has the power for health care decisions to a loved one.

Regarding the medical aspects concerning the particular problem,  25-50%  of
Parkinson's patients will develop some sort of dementia- which may or may
not lead to serious enough disability that the person is unable to conduct
his own affairs. The definition of competency is a legal one rather than a
medical one.

At minimum I certainly would not want the decision made about my life to be
made without an strong attempt to obtain my consultation. If I was in a
position to make such a decision but according to my power of attorney for
healthcare document my wife knows my wishes and will act accordingly. (Which
is to not prolong my life unnecessarily).  Being locked up in my body
without ability to speak  and communicate is certainly a fear and a
possibility for me.   I wouldn't want to have cardiac
resuscitation done to maintain that quality of life-  but that is my
preference.

I think that all efforts should have been made to communicate with Mr. S
Prior to any decision being made regardless of how he looked.

Regarding the pressure that was put on the wife in this case I think it is
reprehensible unless her husband had expressed other wishes to her.  Then it
is still tragic since she appears to have needed the time to say goodbye and
the treating MD.s were unwilling to allow it to her.  At the same time the
tracheotomy against the will of the wife and favored by the physicians shows
that the wife  was ambivalent about  less drastic life saving procedures
being employed.

Having said all of that I feel that DNR orders prevent very few deaths among
elderly even those who are healthy and the issue is probably not a big one
except on principal  that one should when possible have control over how
he/she
dies.

Charlie
Charles T. Meyer, M.D.
Middleton(Madison) WI
[log in to unmask]


----- Original Message -----
From: Dennis Greene <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, January 27, 2000 3:43 AM
Subject: PD / cognative ability / and the law


> The letter below is self explanatory.  I am forwarding it to the list
(with
> Ms Spanker's knowledge and approval) and have undertaken to forward to her
> any response you good folks may care to make.
> Dennis.
> +++++++++++++++++++++++++++
> Dennis Greene 50/dx 37/ onset 32
> There's nothing wrong with me that dealing with PD won't fix!
> email - [log in to unmask]
> Website - http://members.networx.net.au/~dennisg/
> (most recent update -Nov 5, 1999)
> +++++++++++++++++++++++++++
>
> Dear Mr. Greene,
>
> I've been enjoying your website. In particular, it helps me better
> understand the nature of the disease  and the "real" ways it affects a
> person's life.
>
> I have a question I hope you may be able to answer. From what you know
> of the disease generally, what, if anything are the cognitive effects  of
> Parkinson's ? Stuff I read sometimes says "no effect identified ",  or
says
> "not in the early stages...". What's the scoop?
>
> The reason I ask, has to do with  a legal case  I was analysing for our
law
> commission last year. It was describing the ways that  the law is involved
> in "older adults' personal relationships."  In this particular Canadian
> case, a husband and wife  ( Mr. and Mrs. S. ) went to a major health
clinic
> to have his condition assessed (his condition had been deteriorating).
They
> lived  out in the country, and  the clinic was in the city.
>
> Mr. and Mrs. S. were in their late 70s. Mr. S. has  had Parkinson's
disease
> for at least 20  years, and a bunch of other health problems more
recently.
> At the health clinic,  the doctor in charge  wants to put a "do not
> resuscitate order" (DNR) on Mr.S.'s chart. Mrs. S. was adamantly  against
> this.  The Dr. backs off for the moment.
>
> [ Normally you ask patients what they want in terms of treatment, none
> treatment, as long as they are mentally competent.  If they are not, they
> you normally go to their  "proxy" or "substitute decision maker"
>
> At this time, Mr. S. has a lot of trouble communicating  because of the
> Parkinson's disease. In the following months, the Dr. continues to try to
> persuade Mrs. S. that there should be a "DNR" order for her husband.
[little
> mention in the case of whether or how hard  the doctor tried talking with
> Mr. S.]    Later, doctors orders a tracheostomy-- now Mr. S. can't
> communicate his wishes at all.  Mrs. S. objects to that operation too.
>
> Doctors "leap frog" her-- and  they go to the Public Trustee to have  a
> protective order placed on Mr. S.-- now they don't have to talk to Mrs. S.
> at all.
> A DNR order is placed on the chart.  Mrs. S. goes to court  to get an
> injunction to get the DNR  order removed from her husband's chart.
>
> Mrs. S. spends countless hours a day at hospital with her husband and
says--
> " listen I spend all this time with my husband, I can communicate with him
> and I know what he wants. " Doctors and nurses basically suggest  "you are
> silly old woman who really haven't come to terms with your husband's
> condition.  He can't communicate with you or he doesn't understand what's
> going on ...You are just afraid of being alone... We know what's best for
> him and he should not be resuscitated if he goes into cardiac arrest" (I'm
> paraphrasing and editorializing)..
>
>
> The Issues
>
> This case really bothers me for a lot of  reasons-- I really see a lot of
> older people's rights being trounced upon in health care because they are
> seen as "less valuable" or "not worth the effort".
>
> Mr. S. was ignored in this whole process-- doctors appear to have assumed
> he was not mentally capable of expressing his wishes, largely because he
> could not communicate; so they leapfrogged over him and went to his wife;
> and when she didn't give them the answer they wanted, they leapfrogged
over
> her to go the Public  Trustee, who basically said to the doctors "You
decide
> what's best"...
>
>
>
> But that brings me back to my question : From what you know of the disease
> generally, what, if anything are the cognitive effects  of Parkinson's
> disease on the person?  Does it leave some people mentally impaired at
some
> stage. Or are the thoughts still in there and they can't get out? I'm
> wondering  if  the one of classic  signs of Parkinson's  ( blank
expression)
> could easily be misread as  "not being all there."
>
>
>
>
>
>
> Charmaine Spencer
> Gerontology Research Centre
> Simon Fraser University
> 2800-515 West Hastings  Street
> Vancouver, B.C.
> p: 1-604-291-5047
> f: 1- 604-291-5066
> email: [log in to unmask]