An excerpt from At Peace: Choosing a Good Death After a Long Life. Copyright © 2018 by Samuel Harrington, MD. Reprinted with permission of Grand Central Publishing. All rights reserved.
The momentum to treat in America is unmatched around the globe or throughout history. As a result, we spend twice as much on medical care as the next most expensive country. A very large percentage of that money is spent in the last six months of life.
What fuels the momentum to treat? American exceptionalism, for one. This is an ingrained feeling that the United States and its citizens are not only different but are the best, have the best, do the best, and deserve the best. As a result, most Americans pridefully believe that American medicine is the best in the world. These Americans are dead wrong. Compared with other developed countries, American medicine is unexceptional except in terms of cost, convenience, and self-promotion. In terms of things that matter — such as life expectancy, infant mortality, or quality of life after sixty-ﬁve — the United States ranks in the lower third of developed countries, sometimes dead last. Yet American exceptionalism inspires acquiescence in patients, which makes resistance to treatment almost unpatriotic. When coupled with the proﬁt-over-principle mentality of providers, this momentum to treat contributes to the medicalization of death.
Three years before leaving my practice, I met an elderly patient who developed late-onset ulcerative colitis. Vigorous for an octogenarian, she was a comparatively active socialite who found that the bloody diarrhea and near incontinence that her disease caused was unacceptable. I was sympathetic, and we were both disappointed by her response to standard therapy. Through advertisements, my patient was aware of inﬂiximab (brand name Remicade), an infusion that altered the immune system. I was hesitant to start such a treatment because of her age (there were limited studies performed in elderly patients, and there were many warnings against its use in that population), but she and her family were insistent. We sought the advice of an expert in inﬂammatory bowel disease.
Unfortunately, the physician providing the second opinion promoted and initiated the new treatment. In the end, it proved easier, less time consuming, and more proﬁtable for the expert simply to plug the patient into their assembly line than to explain repeatedly why she should consider resisting that system. Shortly after the ﬁrst infusion, the patient reported a dramatic improvement in her bowel symptoms. Two weeks later she was admitted to the ICU with double pneumonia caused by an organism released by her weakened immune system. Still, in the ICU, she died two weeks after that.
This patient remains a case in point. At $4,000 per infusion of inﬂiximab, she was unlikely to undertake it without Medicare reimbursement. She believed the advertisements that exaggerated the beneﬁts and minimized the risks. She did not believe that her life could or should be limited by illness at her advanced age. Instead, she died prematurely and suffered a medicalized death.
Samuel Harrington is a gastroenterologist and author of At Peace: Choosing a Good Death After a Long Life.
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