The consequences of doing everything in end-of-life-care

Fear-mongering about health care reform killing grandma really burns me: I have delivered “everything”, I know what “everything” looks like. I know its dark side. I also know that these deliberate and self-serving lies will ultimately hurt not only grandma, but the rest of us too. Here is what I mean.

When I was in practice I cared for critically ill patients. I loved the ICU for its complex physiology and its palpable human dimension. Unfortunately, my practice afforded me many opportunities to understand the pain and frequent futility of interventions to prolong life without regard to its quality.

Often the intensivist is first to address end-of-life issues. In a typical scenario, an elderly patient is hospitalized with pneumonia. The primary care physician, with a long and meaningful history with her, has never broached her wishes should she require heroic interventions. Nor has she shared them with her family. Possibly she has not thought about it herself, despite her chronic health problems and advanced age. So, now she is on a ward, deteriorating despite appropriate care. She is in extremis and will die without immediate help. The intensivist, with no prior relationship with her or her family, has seconds-to-minutes to decide on the best course of action. The family opts for “everything” without a clear understanding of what it entails.

What “everything” looks like should strike fear into your soul: days-to-weeks on a ventilator delivering breaths through a plastic tube, generating pain, horror and gagging discomfort. To keep grandma from pulling her tube out and damaging herself, she is given constant sedation, and sometimes paralysis. And the tube is only the beginning. She will get other invasive interventions, whose value to recovery is questionable.

The gut-wrenching decisions come several days into “everything”, when grandma’s heart, pummeled by years of coronary disease, cannot pump enough blood to her vital organs, her kidneys have shut down, she has developed infectious diarrhea and low blood counts. You, the family, have to make decisions about invasive heart tests, colonoscopies, transfusions and dialysis. At this point I, the intensivist, must tell you that grandma is unlikely to survive, and to continue “everything” is counterproductive, even harmful to her. And if she does survive these weeks, she is unlikely to return to her independent life, and will probably be dead within the year. So now you have to decide: do we keep grandma on “everything” in the hope that she lives, thus consigning her to a short and quality-free life, or do we make her comfortable and let her drift peacefully into Lethe by having me, the intensivist, stop “everything”?

These scenarios are now playing out every day across our nation. It is a blatant lie that an honest discussion about end-of-life care amounts to killing grandma. It is a lie that doctors want to euthanize their patients in the name of cost cutting. It is absurd to believe that death will be statutorily mandated in the US under any circumstances. We must focus on efficient and humane delivery of health care.

May common sense prevail.

Marya Zilberberg is founder and CEO of EviMed Research Group and blogs at Healthcare, etc.

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