Futile care has human and financial costs

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.

Doctor Grumpy is a neurologist who blogs at Doctor Grumpy in the House.

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  • dud

    You are right on.

    Not sure how to fix it. I really liked the advanced directive discussion that was occurring before the death panel stuff drowned it out.
    It would seem end of like discussions would be part of being a good physician, I’m not one, so I may be way off. It surely is part of being a good/informed patient. Tough to put my family and my doctor in a position of having end of life discussion when I am actually at the end of my life and perhaps they are not ready to let go.

    It is too complex an issue for both political parties so they will just ignore it.

  • http://glasshospital.com John Schumann, M.D.

    Hey dud-
    Right on. You bet these conversations are a crucial part, perhaps even THE most crucial part of a good physician, at least one who takes care of people at the end of life.

    I agree with you, too, that since end of life brings up so many conflicting emotional feelings that lawmakers will tread ever-so-warily in this direction, as in the ten-foot-pole type of wariness.

    I like Dr. Grumpy’s post a lot. I blogged something I call “A Good Death” here:

    http://glasshospital.com/2010/02/25/a-good-death/

    Dr. John (aka GlassHospital)

  • Happy Hospitalist

    What are your thoughts about coding a dead heart?

    http://thehappyhospitalist.blogspot.com/2010/03/end-of-life-ethical-issues-when-doctors.html

    Apparently, some people think that’s my job.

  • http://bittersweetmedicine.com/ Dr Lemmon

    The case you describe is perfect for a death panel to resolve. In fact I don’t think any physician is obligated to provide futile care in a situation like that. But, to cover all bases, the case could be handled by a death panel.

    The concern is that a patient, healthy and high functioning, might be denied a surgical procedure because they are old and not expected to live long enough to justify the cost. I have a 92 yo patient, functions like a 65 yo. Should he be denied a surgical procedure because of his age and expected life span? I don’t think a death panel is appropriate in this case. It should be between the physician and patient only.

    And we shouldn’t use the term death panel. How about life panel, or health panel or patient advocacy panel. Sounds better.

  • Primary Care Internist

    Terrific post. From my perspective (primary geriatrics) I’ve seen this type of situation a lot also. I’ve proposed before the following:

    1- have families seeking futile care for their loved one pay just ONE PERCENT of the associated costs of hospitalization, ICU stay, etc. Many times I’m put in the position of trying to present palliation as an option to an unrealistic family. Unfortunately I see too often the decision to “do everything” and I agree, if patients’ families had to cough up say $1000 for every $100,000 is not too much to ask. That means the taxpayers (for a medicare/medicaid patient in NY) still pick up NINETY-NINE PERCENT OF THE COSTS FOR A TERMINALLY-ILL patient.

    2- Give REAL protection against frivolous lawsuits to doctors who just say “NO WE AREN’T GOING TO DO THAT TO YOUR MOTHER” when such care is futile. Of course for such cases physicians would likely win, but it’s easier to ship Grandma who is terminally demented and septic with pneumonia to the hospital to get intubated, stay in the ICU for 2 weeks to eventually die anyway, but get 6 specialty consults, 10 radiologic procedures, endoscopies and endless blood tests on the way downhill; than to answer to an ungrateful and unrealistic family and slimy lawyers who have nothing to lose by suing you for neglect. Or worse, criminal charges a la Ana Pou.

    The frustrating thing to me is listening to all the gibberish health reform “debate” that is so detached from the realities of doctoring. The most ridiculous thing to me about the administration and our political reps’ totally ignoring doctors in the process, is that we know better than anyone how & where the money is spent and where to target waste, especially in geriatrics. Hospitalizing a patient like the one I painted above, might cost the taxpayers more than $1 million, JUST FOR THAT ONE PATIENT! Imagine just giving that money to pediatricians to vaccinate kids, say $1/vaccine extra for a million shots??? Most pediatricians lose money on vaccinating, and we need to stop this insanity for the next generation.

  • Internist

    I agree it’s sad. I agree w getting ethics panel involved. I don’t agree w death panels ( or life panel) to decide things. Decision should b w physicians that know the case in concert w family if pt cannot speak for himself.

    I also think physicians should not b forced into providing care that is futile, as in this case. First do no harm…we do these patients major harm and all for nothing.

  • gerridoc

    Decisions regarding continuing to provide medical care for patients in situations similar to the ones described by Dr Grumpy and the Happy hospitalist are becoming all too common. It is also a topic that the public chooses to ignore. I made it a practice to ask patients if they had written Advance Directives during routine office visits. Not many of them had done so, and even with encouragement, they were not likely to follow through.
    Recently, there was a front page article in the Sunday edition of the Philadelphia Inquirer about a local hospital’s efforts to help educate families and to provide support while they discussed treatment options for a family member with a critical medical illness. There were some responses from physicians who lauded the article as an excellent representation of the dilemmas faced by families every day in hospital settings. I don’t think that there was one response from a non-medical person. It seems to me that the public has chosen to ignore the issue.

  • http://drgrumpyinthehouse.blogspot.com Dr. Grumpy

    Gerridoc- you are correct. Very much ignored by the public. I actually received a comment from someone who claimed that health care workers were making up these stories and exaggerating their frequency.

    http://drgrumpyinthehouse.blogspot.com/2010/03/opposing-viewpoint.html

  • http://www.consentcare.com Martin Young

    I just hope like hell my family never does this to me! Dying is not the worst thing there is. This sounds like torture, and the real pathology is in the family, not the patient.

  • gerridoc

    Dr Grumpy:
    I read the comments on your blog. You have another fan.

  • mark

    You are correct….this is happening over and over in every single hospital in the country. We could easily afford some basic national health plan if we stopped this nonsense. The government will have to be better at saying no to this nonsense than insurance companies otherwise the country will be destroyed by a relatively few people whwo want to torture their loved ones to death.

    If you want this nonsense then you pay for it out of your own pocket.

  • BobBapaso

    Health Care Savings Accounts, for everyone, are the answer. If the family had been signing checks for her care out of her health care savings account, which would roll over into theirs when she died, she never would have gotten as far as to Dr Grumpy.

  • http://www.RealNurseEd.com Cyndi Cramer, BA, RN, OCN, PCRN

    I love the 1% idea!
    And Patient Advocate Panels sounds like a great idea.

    I also see the reverse (all to frequently) where patient’s families want to “stop the insanity” and the MD refuses to admit they can’t still “fix” the patients…
    How terrible to be conflicted and sorrowful over the loss of your spouse, and you have an MD telling you they can still make them better and you want them to die!!

    Ethics panels have no teeth. And without Tort Reform, Physicians will continue to fear lawsuits if they don’t do everything imaginable (& unimaginable) to stop death…

    But, under NO circumstances, do I want any politician or government bureaucrat making these kind of decisions (just like I don’t want health insurance companies making them)
    So, I guess we’ll just spin in circles while Washington argues some more…