End of life

I had an elderly gentleman roll in to clinic today at the VA. We have been following a pretty large non-healing surgical wound due to advanced peripheral vascular disease to the left leg for the last month. Last week it looked manky with exposed bone at the tip of his second toe, but there was some improvement in the wound over last week so the podiatrist I was working with that day sent him back to the nursing home with instructions to the nurses re: bandage changes and a course of Cipro.
In clinic today that toe looked awful and smelled mighty interesting to boot. Worse, the patient was now A&Ox 1 with a temp of 102F. ER admit, right? Below the knee amputation to the offending leg and hope there's enough circulation that high up to allow the wound to heal this time? The family responded that they didn't want him admitted. They didn't want any surgeries. That we should send him back to the nursing home.
My first thought was that the family didn't really understand what was happening, that they were going to kill their grandfather through ignorance. After a long phone conversation however it sounded as though they wanted him to be admitted too. Their grandfather and they had had multiple conversations about future hospitalizations, future surgeries, and live extending procedures and it had been his wish not to undergo any further amputations. (Like I said, bad PVD and it showed.) We finally sent him back to the nursing home. I with a sinking feeling in my heart.
So I think I'm most astonished with the fact that I was standing next to a patient today who made a rational, thoughtful decision about how he wanted to end his life; a patient who has the beginnings of a septicemia and will now die soon.
I was surprised at how outraged I had felt that the family didn't request heroic life saving measures for their loved one. And yet I KNOW that even if successful it would be the beginnings of the end for this particular patient. I KNOW that the most money spent by Medicare is done in the last weeks of a patients life. Spent wisely? Spent with the patients' quality of life in mind? Or is it spent preserving a life because we don't know how to do anything else?
I'm glad that the patient had discussed his wishes for end of life care. It definitely felt creepy sending him home, but hopefully that's what the patient wanted instead of being left in the forceps of modern medicine.

Noah