NPF: THE GREAT BEYOND

Posted in No Politics Friday on January 28th, 2011 by Ed

Because "no politics" doesn't always mean that Fridays will be full of funny.

Frontline has been knocking it out of the park this season and I just got around to watching "Facing Death", a highly recommended look at patients and families in intensive care units making decisions about using advanced technology to prolong the lives of patients with no hope of recovery. We see respirators in comatose stroke victims, cancer patients in their final days, and $250,000 bone marrow transplants that buy terminal patients a week or so (at best) of poor quality life.

It is easy for the home viewer to watch these patients and think "Give it up, man." The doctors in this hospital are remarkably frank, as I imagine most doctors in those situations prefer to be. They let patients know in no uncertain terms that additional, intensive, and often expensive treatments are not likely to prolong life and offer no hope of recovery. At best, it buys a small amount of time that might be spent heavily sedated, comatose, or in agonizing pain. The family members who refuse to take their 90 year old mother off the respirator seem delusional to us. We would all like to think that we would be more rational in the same circumstances. Call me skeptical.

Is any of this worth it? Do doctors need to do an even better job of telling people "Look, this half-million dollar liver transplant is going to buy you a week or two and then you are going to die anyway" or are they already too eager to talk patients they consider terminal or hopeless out of treatment? When doctors do advise radical procedures to terminal patients, are they doing it to "practice"/experiment or do they actually think that it will offer meaningful benefits? This must be a very hard line for health care providers to toe. I can imagine cold, emotionless doctors who write off patients with terminal diseases at the drop of a hat, potentially denying treatments that might provide legitimate benefits. I can also imagine doctors who are unrealistically optimistic, insisting on throwing the kitchen sink at every patient no matter how hopeless. There is no easy way to balance those concerns.

People die in hospitals much more often today than ever before. We see this as progress, a sign of the broadening of access to advanced medical care. It is fair to question, though, what is accomplished by spending limited resources and obscene amounts of money to treat people who are barely alive and aren't going to get better. Shouldn't the patients tell the doctor "No more"? Shouldn't the next of kin face reality and take Mom off the heart-lung-dialysis machine after months without improvement? From a moral or practical standpoint it is a slam dunk. Resources are better spent on patients who might actually improve with treatment, and literal billions of dollars are spent on mechanical life extending interventions that serve no real purpose. I have reservations nonetheless.

My opinion stems not from a religious or moral principle but from a sense of caution. Until we are in that position ourselves, none of us can say definitively how we will react and what we would want – for ourselves or our kin. Who really knows what happens when we reach the end? Anyone who still has meaningful levels of brain activity has some kind of quality of life. Maybe the last day is when we have the vision / dream that explains the meaning of life. Maybe one more day with the family, even if unable to move or speak, is worth any amount of money. Maybe the small amount of extra time is enough for people to figure things out and make peace with what is happening to them.

Before you grab the pitchforks, let me reiterate that I do recognize practicality as an issue. People who are brain dead should not be sustained. Bone marrow and organs should be directed toward younger, healthier patients who might actually recover. Doctors and patients do need to do a better job of saying "There is no hope for improvement. Further treatment beyond making you comfortable is futile." Some people can't let go and waste hundreds of thousands of dollars and man-hours seeking a miracle recovery up to the very last minute. Nonetheless, never having been in that position (directly or as the family member making decisions on a dying person's behalf – I've been pretty damn lucky so far) I am hesitant to argue too strongly against end-of-life medical expenses. Sure, the 30% of all healthcare costs spent in the last year of life could be seen as "waste". Maybe it is. Maybe doctors should tell terminal patients to do what humans have been doing for thousands of years – go home, go to bed, and wait for the end. But at the same time, we have to recognize that we are making some mighty big assumptions based on how little we collectively know about what happens at the end and what value, if any, is derived from buying small increments of additional time at great cost.