A Simple Girl Walks into a Clinic
by Bella Rum
“I hate people who die of natural causes; they just don’t understand the moment. It’s the grand finale, act three, the eleven o’clock number — make it count. If you’re going to die, die interesting! Is there anything worse than a boring death? I think not. When my time comes I’m going to go out in highs type. I have no intention of being sick or lingering or dragging on and on and boring everyone I know. I have no intention of coughing and wheezing for months on end. One morning you’ll wake up and read a headline: Joan Rivers Found Dead…On George Clooney’s Face. Clooney Was So Bereft All He Could Say Was, ‘Xjfhfyrnem.'” — Joan Rivers
Well, it wasn’t exactly like that, but close enough, Joan. We didn’t have to watch your slow slide into dependency like so many mere mortals. You all know by now that Joan Rivers died a week after a minor elective procedure at a Manhattan medical clinic, and that’s what I want to write about – the decision to have the procedure performed in a facility other than a hospital.
Joan stopped breathing and went into cardiac and respiratory arrest at Yorkville Endoscopy. She was then transported six minutes across town to Mount Sinai Hospital and died on Thursday. The outpatient clinic is under investigation by the New York State Department of Health. The New York medical examiner office is also investigating her death.
As people get older, it is not uncommon for them to take their spouses into the doctor’s office with them. There are a few reasons this is a good idea. If a person has significant health issues, there could be a lot to remember. Four ears are better than two, and two brains are better than one. If there’s a decision to be made or a procedure or operation or even tests to consider, maybe the supporting spouse would like to weigh in. Maybe one or both spouses feel more comfortable making these decisions together. Maybe it’s a child/elderly parent situation, and the child wants to be in the room.
H and I do not do this… yet, but many do, and I can see why.
We both had colonoscopies a few months ago. H has Medicare and Medicare requires this procedure to be done in a hospital setting. However, I do not enjoy Medicare yet, and my doctor (the same doctor as H’s) suggested that it would be less costly if I underwent my procedure at an outpatient clinic. I chose the outpatient clinic option, but H was not in the room when I made the decision.
Let’s say that H wasn’t keen on the idea of an outpatient clinic and this is why. My heart and lungs are compromised. That is to say that neither of them work just right. He would have felt better if I had chosen the hospital setting and all of its personnel, backup systems and plethora of doctors and just paid more. Now that I think about it, I should have waited a year, and I would have been on Medicare. That would have saved a lot of money and discussion in my house, but all is well that ends well and all that.
So, when I heard about Joan going into cardiac and respiratory arrest, my mind immediately went to those decisions that she made about the location of her procedure, and I wondered if she would have fared better if the procedure had been done in a hospital. I thought from the first day that she would not recover or at least would not be the same Joan she had always been. I suspected that her famously quick brain had been deprived of oxygen too long. Having a hunch about her wishes surrounding death and dying, I hoped she would get to do it her way, and while we do not know all the details, it appears that her daughter made sure of it.
So what’s the answer. Should we go to an outpatient clinic or choose a hospital setting. Well, like most things… it depends. This is what Dr. John Abenstein, president-elect of the American Society of Anesthesiologists has to say.
“It can be done safely under many circumstances,” he noted, adding that what’s most important is assessing a patient’s underlying health status, functional status, medical history, and the risk factors of the procedure itself.
One of the first questions he asks patients when deciding whether to move forward with a sedated procedure is if they can walk up two flights of stairs. “If the answer is ‘yes,’ it’s most likely appropriate,” he said. If the answer is “no,” he dives deeper to uncover why—to find out if it’s because of arthritis, for example, or a cardiovascular issue, which could be a red flag. “Cardiopulmonary function is what we concentrate most on,” he added. That’s because the highest risk with anesthesia in general, he said, relate to the depth of sedation, and the fact that the deeper one is put under, the harder it is to breathe and protect oneself with reflexes (the gag reflex, for example).
And here’s what Kevin Campbell, a cardiologist and heart-rhythm disorder specialist has to say.
“I prefer older patients with risk factors to have procedures done in a hospital, just in case,” he said. “Sometimes in an outpatient setting it’s a different mindset, and I worry that they sometimes cut corners.”
Still, he agreed that it was often appropriate for an elderly individual to undergo an anesthetized procedure in an outpatient clinic. “It depends on the procedure,” Campbell said. “If it’s a low-risk elective surgery, with low-risk sedation, and various criteria are met, then it’s probably acceptable.”
Before submitting to the operation, he advised, a person “should be evaluated by a primary-care doctor and get pre-op clearance from a cardiologist.” It’s also advisable for patients to find out as many details as possible regarding the clinic’s plan for administering the anesthesia— what sort it will be, what the possible risks and side effects are, what the emergency plan is in case something goes wrong, and even who will be administering the sedation.
Do your homework, talk to your doctors, ask questions and make an informed decision. Joan Rivers had heart arrhythmia. I don’t know if it complicated her situation.