Science Guide

Last night I got an urgent call to go to one of our ICU's. An elderly woman was having a (slow) dissection of her ascending aorta and was probably going to go to surgery. The surgeon in charge of the case was waiting for family to make a decision. The patient was stable at that time.

This woman was in her 80's, moderately demented and was currently in the ICU for a major infection. She had been living in a high level care nursing home. I reviewed the patient's echo and clinical status. I told the surgeon waiting for the family, that my best guess was that we were looking at about 25% chance of mortality on the OR table and probably another 50-60% if the proposed graft did not become infected. Probably about 100% if the graft did become infected. The family informed the surgeon that the patient had asked that if she were ever in a nursing home, that she not have major surgery. That request was honored.

In an acute setting, this case represents a dilemma we face with our health care system. At some point, we need to address costs. It is my firm belief that no one approach will solve this problem. Single payer or larger insurance markets still will not be effective at addressing the ethical/moral side of cost benefit analysis, especially at end of life events. While my scenario is not uncommon, there are more situations where people face costly treatments which, on average, may extend life only by a few weeks or months.

Who makes these decisions and how will we make them? First let me articulate the difficulties in applying probabilities to any specific patient. It is often difficult. In trauma, we have developed some good, very reliable algorithms. In the rest of medicine, our predictive powers are less reliable.

Next, we need to acknowledge that technology has forever changed medical economics. It is possible to develop therapies that will produce real, but small improvements that may be very costly. Therapies that are highly effective but relatively costly are often used in patients that have co-existing diseases which will likely limit the lifespan of that patient anyway. As an example, do we do a total knee replacement on a patient with end stage heart disease or cancer who, statistically, has but a year of life expectancy?

Ok, ok you say. All this can be worked out if we just let the markets go to work. This certainly feels like an abdication of moral responsibility to me. I would prefer that we face this issue head on, rather than let it be decided by which lobby is best at getting its treatments approved for payment. The current crisis in our financial system has also shown how driven by emotion the market can become. All it would take is denial of care, even if reasonable, to one sympathetic figure, and the ensuing media campaign, to make said therapy mandatory for everyone.

Let God decide you say? God, alas, seldom sends written instructions for individual patients. Let the patient and family decide? In our current system, on Medicare, they are divorced from much financial responsibility for their decision. I think there is a need for families, physicians, religious leaders, economists and the taxpayers to all participate in a large scale discussion about who decides when we die, and how to pay for our decision.

Steve