Check Out Time (a neurologist's take on end of life care)

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I'm sure I'll get flamed by somebody over this post, but I've been stewing over this for a few weeks, and just want to say it.

I haven't ever saved a life. No doctor has. We may prolong the inevitable, but we don't save anyone.

We aren't immortal, and weren't meant to be. We die. All things do. Plants, animals, even stars.

Death is as much a part of life as birth.

And yet, at times people chase medical science as if we have immortality in all our gadgets and pills.

Why am I writing this?

A few weeks ago I had a hospital consult on a horrible, awful, sad case. Lady in her 60's with advanced cancer. It had spread through every organ of her body. Brain, lungs, bones, liver, intestines. You name it.

She'd had surgery. And radiation. And chemotherapy. Established treatments. Experimental treatments. Alternative treatments. Her husband had taken her to every major cancer center in the U.S. (using YOUR insurance premiums, of course). And every single one told them there was no hope. So he fired them and moved to the next center.

She landed at my hospital, somehow. Sick as shit. Ended up a ventilator. Tubes in every orifice. Comatose from every body system failing. Suffered a bleed into the brain. Seizures. You name it.

We health care people have seen this stuff a million times before. But my readers who aren't in the field may not have. And trust me, this situation happens A LOT. More than you'd ever believe. The media leaps onto cases like Terri Schiavo as if they were rarities, but in reality cases like this are frighteningly frequent, every day, in every hospital in the country. Really.

And of course, her husband is beyond denial. He's not a bad person, just hears only what he wants to. He has the room covered in family pictures and religious symbols. He tells me his family is hoping for a miracle, and knows it will come.

So who is he REALLY doing this for? Not for her. To the sad shell of what was once a beautiful, vibrant woman what he's doing is more likely some form of torture. She's gone, sir. Elvis has left the building. But he won't hear that, no matter how many doctors, in innumerable ways, and many times, tell him.

Ask yourself: How do you want your life to close down?

How many of you said you want to die incapacitated in a hospital bed, with plastic tubes in your urethra and butt, and down your throat? And another one in your nose? And maybe a 5th one in your abdomen, going directly into your stomach? With IV lines going into veins in both arms, the few veins that haven't already collapsed from repeated IV lines in them. And the tube in your throat keeps forcing air in and out. Does that sound like a comfortable way to end your days?

I'm not, by any means, arguing against critical care. Some people end up like the above, with a realistic plan of recovery. And many do. I'm talking about people where this is done with absolutely no goal other than to drag life out for as many seconds as possible.

And so back to my lady. Me and 4 other docs (neurology, cardiology, pulmonary, renal, and oncology) had a 1 hour meeting with husband and his grown kids. We told them this was futile. That what we were doing to her was prolonging her suffering. They all listened. They accused us of being "too negative". The next day they transferred her to another hospital. So I have no idea what happened after that.

Beyond human suffering and reason, let's look at this in the cold hard facts of money. Yeah, I'm sure you Sarah Palin fans will accuse me of putting a price on human life. But hell, your insurance company already does, whether you want to believe that or not.

This woman's care has cost at least a million dollars here, likely a hell of a lot more. I'm pretty sure this family's premiums don't cover that, and I know they aren't wealthy. So the money is coming from their insurance company, which is YOUR premiums.

So let's say futile care for this woman cost $1.5 million dollars. Would that money be better on helping treat people who had a more reasonable chance at recovery and significant quality of life? Maybe several?

Yeah, this is a slippery slope, and there's no easy answer as to where you draw the line. The military deals with this in battlefield or disaster area conditions, where you put your resources to those who are salvageable, and letting those who aren't die. But you can't say that in the polite world of modern medicine.

But for all the controversy over the phrase "death panels", ask yourself this- are they so unreasonable? In a case like this, should, say, a panel of 3-5 certified doctors in oncology, with no ties to the patient or the insurance, objectively review the the data and say "Stop this madness"? Or maybe determine further treatment would be beneficial?.

If they decide it's futile, I'm not saying that treatment should stop, but at that point the insurance company can end it's involvement and the entire financial burden falls on the family. I suspect that when they realize realistically how much futility costs to torture a loved one, they'll let her go.

Money, unfortunately, is a finite resource. You have to pay hospital staff, and drug costs, and facility electric bills, and supply bills. In a perfect world I could support my family and care for patients for free. But I have a mortgage and kids and bills, too. As do the nurses and other hospital staff.

Balanced against this finite resource is human suffering. Which is infinite. And you can't keep paying unlimited need with limited resources. In any situation.
Posted by Grumpy, M.D. at 4:16 AM

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http://drgrumpyinthehouse.blogspot.com/2010/03/checkout-time.html