Money driven care punishes both the rich and poor

Recently I met the husband of a patient with a diagnosis of advanced lung cancer. Even though she was young and had been healthy, the disease spread to her bones.  I outlined treatment for this incurable illness: choices, goals and side effects. This was a very tough meeting, because by the end we had to discuss time as measured by dollars.

The particular challenge was that this family had health insurance with a large co-pay.  This meant that they would pay 25% of any medical bill. In addition, his wife had been the major breadwinner, their children were still in school, and the couple had limited financial resources.  Any therapy, which his wife received, would likely have a direct effect on the lives of the family, perhaps for years to come.

No matter what we did, she would die. Treatment would be palliative, designed to improve quality of life and perhaps extend her survival for weeks or a couple months. The best therapeutic alternatives included “active” medications, which would easily cost tens of thousands of dollars, even for a single added month of life.

This loving husband, to both his wife and children, tried to calculate how much money to spend on the possibility that his wife might live, with cancer, for a short time longer.  What would be the quality of that life?  How would spending all their savings, going deeply into debt to buy a few weeks, affect the lives of the children.  Was it worth the cost?

He did not know what his wife desired.  He had not spoken with her about this terrible dilemma.  He found it incredibly hard to put her in the position of deciding whether to stop or limit therapy, and thus give her children a better life after she was gone, or to fight the disease, and try to give her children more time with her now.  Add to this the dilemma that she might also be determining how long she would live, and he found himself unable to add that much pain to her heart. How many of us could hurt someone we love with such a burden?

After a long discussion, I convinced him that as much as he loved her and wanted to protect her, that it had to be his wife’s decision.  I reassured him that when the three of us met, I would be gentle and patient, and would not corner her into a place of desperation.  We would move step by step, maybe even treatment by treatment, to protect her, him, the children and, incredibly, their bank account.

In the kind of event, which happen so often in oncology as to make one wonder about a divine hand, we never had that meeting.  Before we could act the cancer spread to the base of her brain and she was admitted seizing and septic.  As per her prior wishes, she was not placed on a machine and died within days.

We live in a cruel time when the price, human and financial, colludes to crush patients.  Though more than a third of families will spend their last dime on medical care, we continue to develop and support therapies that often have marginal benefit, at massive cost.  In a Kafkaesque twist, it is not clear that spending great amounts improves life’s length or quality.  Money driven care punishes the rich, while the pain of illness and the guilt of too little punish the poor.  The disease from which we suffer is not just of the body, but of the medical system itself.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • Suzi Q 38

    Dr.Salwitz,
    You story was both moving and enlightening.
    Saying goodbye to people we love is difficult.
    I have seen this scenario all too often in my own family.

    I remember a physician asking me what I wanted him to do as far as end of life care for my 82 year old father in law.

    I still remember the face of a sweet physician, who stood over me and told me that my mother in law (who had died minutes ago), did not suffer when she died. He made sure of that.

    I remember my sister not coming to terms with her husband’s fate when battling pancreatic cancer at 52. With two teenage children, she wanted him to stay alive, even in a bed and in pain for as long as it took her to get used to the idea of living without him. If we even suggested bringing him home like he had requested, she felt it was as if we were giving up on him.

    People cope with death in different ways and I respect that.

    All of it.

    It is easy to say how I would plan my end of life care, but things are different for me. I have a PPO insurance card, with a $3K deductible.
    My children are grown, and my husband has stayed by my side for 33 years. I have lived a good life and want more.
    Your patient was much younger and had different family circumstances. What a huge dilemma. Thank goodness no one had to make a decision, but sad that she had to pass on.

    If you told me that all the pricey medical care would not change my outcome, and I was “going down” fast, I would hop on a plane to Hawaii instead. I would invite as many family members as I could, and have a grand time.
    I would give the cancer and all its treatment “the finger”as I “jumped”
    out of this earth.

    This is all so much more preferable than a hospital.

    Just me. I prefer physicians that are open with me, just don’t tell my husband. He could not take it.

  • guest

    It was nice of you to give the husband so much of your time, particularly since he was asking a question that seems a little inappropriate. What could possibly give a husband these days the idea that he would have any right to “spare” a terminally ill wife the right to make decisions about her own treatment? The fact that finances were being considered as a factor in whether to proceed with treatment for the wife is also a little repugnant. If she was the main breadwinner for the family, it seems that that was her money to spend, and without a doubt, her life to decide to spend it on.

    • Tammy

      I doubt it was a real scenario. It sounded like an out-take from the fictional book by Lionel Shriver, “So Much For That.”

  • Steven Reznick

    There is nothing in the content that indicates that the author did not have the approval of the patient to discuss confidential issues. These are complex issues that require compassion, tact and honesty all of which seem to have been practiced.
    Our healthcare system allows pharmaceutical companies and equipment manufacturing companies to charge and receive obscene amounts of money for their products. The cost of products required to deliver and provide care is higher here in the USA than in the rest of the world. That is why health care costs are so high and families are tragically put in this position.

    • Tammy

      Yes, it would be better if they had lived in the UK, where the State would have made the choice for them. They simply wouldn’t have been given any options: the woman would have been sent home to die.

  • Tammy

    “Money driven care punishes both the rich and poor”

    …I’m sorry, but what do you propose instead of “money driven care”? Are you doctors going to start accepting buttons, or pretty seashells, as payment? Instead of that awful, horrible, evil MONEY?

    Even countries with socialized medicine have “money driven care” – it’s just that the government, not the patient or her family, makes the decision as to what care she’s going to get. It’s the State, rather than the patient or her family, who would 100% have said that the care you are proposing was “too expensive”, and they would have denied it. And that woman and her family wouldn’t even have been given a choice.

    ALL medical care is “money-driven” to some extent. There is no magic pudding, no limitless well of “free money” to tap. Decisions will ALWAYS have to be made as to how much it’s worth to give a young mother a couple of extra weeks of life.

    The only difference between the scenario you give and the scenario as it would have played out under the NHS, is that in the USA it was the family’s choice. In the UK they would not have had that choice, the government (N.I.C.E.) would have just said “no” from the get-go.