The elephant in the room
One of my partners recently sent out a call for an extra pair of hands to help out in the operating room—and with good cause. The patient on the OR table was a woman in her 60’s whose massive stroke had left her hemiplegic, aphasic, and unable to swallow. She weighed well over 400 pounds. Attempts to place a percutaneous endoscopic feeding tube had failed due to her size, and she was now scheduled for open gastrostomy tube placement under general anesthesia.
Even with two experienced anesthesiologists working on the patient, getting vascular access and an endotracheal tube in place wasn’t easy. She was anemic for reasons that weren’t fully worked up, and her blood pressure was alarmingly labile. At the end of the procedure, the patient couldn’t be safely extubated so she went to the ICU. As it turned out, she never left. The family couldn’t agree on any reduction in the level of life support, and after a stormy five-week stay, she finally expired. The cost must have reached hundreds of thousands of dollars, and all was spent on sustaining a patient who had no hope whatsoever of meaningful recovery.
This is really the elephant in the room in all the endless talk about health care costs in America, and it’s a subject that often is considered taboo: the amount of money that we spend fruitlessly on end-of-life care.
I am not talking about comfort measures, hospice care, palliative medicine, or any of the other valuable support functions that ease the process of dying. I am talking about using the full technical and pharmacologic armamentarium available in our tertiary care hospitals to treat people who cannot be restored to health.
In anesthesia, we see this problem every day. As consultants, we are not involved in the decision-making process, but we are the ones responsible for getting desperately ill patients through a variety of diagnostic and therapeutic procedures. There are days when not a single patient I look after is likely to survive six months, or in some cases, ever to leave the hospital.
Some procedures are palliative and are justified on humanitarian grounds alone—talc pleurodesis for recurrent malignant pleural effusion is an example. Others are more questionable. How many lung biopsies on ventilated ICU patients ever lead to a diagnosis that changes the treatment plan and improves the outcome?
I bet nearly every anesthesiologist at some point has asked himself the question, when faced with a terminally ill patient, “Why are we doing this?” Sometimes the answer is that the family is pushing to have “everything” done—out of loyalty, guilt, or an inability to face the inevitable. Sometimes it seems that the primary doctor is casting about to find something else to offer as a treatment, whether or not there is much likely benefit. Once everyone else has agreed that the procedure will be scheduled, the anesthesiologist hesitates to put any roadblocks in the way. Raising any objection will only upset the family. And, let’s be honest—in a fee-for-service system, cancelling the case will deprive both the surgeon and the anesthesiologist of income.
Lately there seems to be a little more intelligent discussion about the millions of dollars we are spending on patients in the last months of life. Dr. Atul Gawande published a thoughtful article titled “Letting Go” in the August 2, 2011 issue of The New Yorker magazine. It focuses most on the experiences of relatively young cancer patients, and the difficulty of balancing quality of life and heroic treatment.
Looking from the anesthesiologist’s point of view, however, we see a different angle. Many of our aging patients suffer from chronic problems that compound to the point where meaningful recovery is improbable. At what point does it become unreasonable to pursue further aggressive, costly treatment with stents and AICDs? Should intensive care units continue to evolve into pre-mortem holding wards?
One of the saddest facts about the health care reform bill is that an important provision was deleted in the final negotiations: one that would have allowed Medicare to compensate doctors for time spent with patients and families to plan for end-of-life care. In the public hysteria over “death panels”, this provision was dropped. However, time-consuming counseling is critical so that patients and families can truly understand their options. The fallback position is to “do everything”, and waste millions in the process.
If anesthesiologists never speak up, are we doing our job as physicians? Or are we ignoring the elephant in the room, and furthering the uncontrolled consumption of medical care at the end of life? There is only so much money available to support health care services, and it needs to be spent as wisely as possible.
A version of this column appeared in the Winter 2011 issue of the CSA Bulletin
4 COMMENTS
Honest and intelligent article.
Thank you!
Karen,
I agree with what you’ve said wholeheartedly. In 30 years of anesthesia practice I often asked myself “Why are we doing this?” and sometimes I asked the surgeon and the internist the same question. You carefully drew the line between fruitless care and compassionate end-of-life care. It’s not primarily about money, it’s about subjecting patients and their families to endless rounds of suffering for a little more cardiovascular survival.
The difficulty, as we’re often told in medical school, is in the details. We’ve all seen the “hopeless case” that turned to “survive and thrive” quite unexpectedly. Families of moribund patients want to believe that a miracle can happen on command for their loved one. So they demand that everything be done, without disciplined discussion of the implications (“No good deed goes unpunished…”).
Even if we eliminate only a fraction of fruitless care in the most clear-cut circumstances, we at least will have done so through education of families, partnering with them to make apparently difficult decisions less fraught with tragedy. Where there is reasonable doubt about salvage of patient function, we of course must do everything possible to secure a good outcome.
I agree that for anesthesiologists, the discussion precedes (our should precede) our presence in the drama, but real progress won’t happen till the family doctors and the surgeons, who assume we can get anybody through surgery and anesthesia, acquire a clearer understanding of the risks and implications of what we do in these extreme situations. This understanding may inform their decisions and allow them to be more nuanced than “Full court press!”
[Reply]Dr. Sibert, a very well written, informative article. I have practiced for twenty years in a very busy operating room handling all sorts of cases from cardiac, pediatric, complex neurosurgery and so on. And I cannot agree more, there is so much unwarranted surgery that takes place, causing not only exponential increases in healthcare costs but often, creating false hope among the families involved. Articles such as these should be published in the general media more often as clearly, there must be more public awareness of what goes on.
We all recently watched with great anticipation as the healthcare debate unfolded on capital hill two years ago. The “death panels” that were described by many opponents of the bill were an example of politicizing an issue for self gain. To the lay person, a death panel sounds horrible and will definitely provide a means for disapproval of any bill that includes such. In actuality though, the concept should be framed as an educational panel-the heightened awareness of the costs associated with futile end of life care should be emphasized to the public in a determined but dignified way. It is not news that the majority of excessive spending occurs in the last two weeks of life. Anyone who has watched a family member knows how tortuous this can be, and they also know how difficult decision making can be at that point in time. Your article is well-written, easily palatable, and blogs like this should be brought out more to the public.
Thanks,
Scott f. mackinnon MD
[Reply]My Esteemed Colleagues:
I agree with you on nearly all points, however, we find ourselves in this position of making hopeless, desperate measures because of a couple unmentioned facts.
1. Patients’ families have minimal financial “skin in the game”. With Medicare/Medicaid as a defined benefit plan, the “sky is the limit” as far as costs incurred. In 20 years of private practice, I have yet to hear any concern from a family member about the “costs” for aggressive care. When a faceless bureaucratic 3rd party covers the costs, the vast majority of Americans will opt to do anything for their demented, ASA 4E grandma with metastatic CA.
2. As long as the current medical liability system remains as is, the costs of “defensive” medicine will weigh heavily in the hearts and minds of physicians. As anesthesiologists, we derive no financial benefit from ordering that stat Echo or repeating a PT/INR (nor do most other specialists), yet we feel compelled to cover ourselves just in case. It irritates me to no end that this president and his party continue to blame “fee for service” medicine for the problems in our HCS. With physician reimbursement at 7-8% of the healthcare dollar, we are NOT the problem yet organized medicine continues to take it on the chin when lawmakers demonize us.
One last point to all the comments above. THERE ARE DEATH PANELS within the PPACA. It is called IPAB (Independent Payment Advisory Board), Center for Health Information Technology (part of 2009 economic stimulus package) and the Federal Coordinating Council For Clinical Effectiveness Research. These are the entities that will control physicians from 2014 and beyond unless the entire law gets repealed.
Thanks for the format to vent!!
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