06/02/2017 10:26 AM Posted by: Pat Leach

SDP Fellows Blog

SDP is continuing a new service: periodic blogs, written by SDP Fellows. In this blog, the second of the series, Pat Leach offers thoughts on decision making related to choices about "Beer and Death".

Beer and Death

I recently went to a pub called First Draft in Denver with my daughter. It is a unique experience – the only pub I’ve ever been in that had no bartenders.

When you enter, they read the magnetic strip on your driver’s license, both to ensure that you are old enough to drink and to put your information on a "key card” they give you (similar to the key cards that get you into your hotel room these days). You then grab a glass and move to the taps – about two dozen of them lined up along one wall with detailed descriptions of the beers written above them, along with each one’s cost per ounce.

You put your card up to a reader above the tap of your choice, wait for the green light to come on, and pour yourself a beer – or maybe just a taste, so you can see if you like it. The screen will show you how many ounces you poured, and what it cost. You are then free to move on to taste another beer, or to pour yourself a full glass if you found a specific brew to be especially to your liking. Once you have found your favorite, there are plenty of tables and chairs at which to gather and socialize. It is a beer connoisseur’s heaven (not that I’m a connoisseur; I just like good beer).

What does this have to do with decision making? Well, every time you use your card to pour a beer, it not only tells you how many ounces you have cumulatively poured, it also tells you how many ounces you have left. Once you’ve had 32 ounces – just two American pints – you’re cut off.

At first, I felt that my constitutional rights had been violated. My daughter and I had walked from her apartment, so we weren’t driving, and if I wanted to have a third pint, that should be up to me! I also thought, "What a weird business model – limiting the amount anyone can spend in your pub.”

But upon reflection, I can see the logic. Having even one or two drinks impairs one’s judgment. Law books are full of examples of drunk driving accidents where the drinking establishment was held responsible for continuing to give booze to someone who had clearly had enough. But it’s up to the bartender to make that judgment, and this place doesn’t have bartenders. Without the 32-ounce limit, it would be extremely easy (and tempting) to overdo it. Even if you ignore the legal responsibilities, First Draft does not want to be sending people out into the night completely incapacitated.

So I applaud First Draft’s culture of social responsibility. This is an example where intervening to overrule someone’s right to make their own decisions is a good thing.

Which brings me to the second part of the title: Death. There was an excellent article in The Economist about how painful (literally, emotionally, and financially) death has become. Two-thirds of deaths in wealthy countries now occur in a hospital or nursing home, often following years of deterioration and sometimes weeks or months of intense medical intervention. In the US, nearly a third of all people who die after age 65 will spend time in the intensive care unit during their final three months.

No one wants to die like this. Very few people prioritize "living as long as possible” over "dying peacefully, surrounded by loved ones.” People who die in hospitals suffer more pain, stress, and depression than people who die at home or in hospice. And yet allowing a terminal patient to choose the time and manner of their own death – i.e., make their own decision on one of the most important issues of their life – remains a delicate and controversial topic. If a cancer patient has had enough pain killers to make them comfortable, to what extent have those drugs impaired their judgment? If a patient is currently marginally coherent, but stated their desire not to be resuscitated back when they were healthy, how do we know they haven’t changed their mind? Will family members who are footing the bills put pressure (consciously or subconsciously) on loved ones to give it up? Lawyers can make all kinds of hay with questions like these. Politicians avoid the subject like the plague, especially since the part of the ACA dealing with doctor/terminal patient discussions was twisted into cries of "death panels!”

In addition, doctors are trained and feel obligated to do everything they can to save a patient who still stands even a small chance of recovery. Whether the patient wants to follow that route is sometimes not discussed. Most doctors have never been taught how to talk to a terminally ill patient about their wishes for the end.

The Economist article concludes that "…honest and open conversations with the dying should be as much a part of modern medicine as prescribing drugs or fixing broken bones.” Doctors are well-trained to assess a patient’s mental state. If the patient is apparently thinking clearly, then despite the uncertainties about impairment from drugs or a patient’s distressed mental state, it is important to help that person to make a well-informed decision – and then honor that decision.

One of the basic tenets of decision science is knowing who the real decision maker is (or should be). In the case a First Draft customer with a maxed-out key card, overruling the decision maker is justified; in the case of a coherent terminal patient, it is not.

P.S.: A number of us are currently in the early stages of planning a conference on Shared Decision Making in the realm of medicine, scheduled for early 2018 (there was one late last year, but I missed it). I hope to have a session dedicated to the topic of making decisions with terminal patients.

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