Healthcare Week: End-of-life care? (Update)

Posted on November 30th, 2010 by ecthompson md

Sometimes, when I see what the mainstream media is talking about, I get physically nauseated. Probably 80% of the time, we are focused on nothing. Whether it is Britney Spears or Reverend Wright or, currently, a pay freeze for all federal employees, we continue to miss the big picture. Freezing pay for federal employees will not solve the deficit. It won’t even come close. It is an excellent example of a stupid policy.

Back to healthcare. About 18 months ago, I sat down to write a book on healthcare. I thought I knew a little bit about healthcare. I’ve been a trauma surgeon for over 15 years. My father, whom I used to help in his office, was a family practitioner. So I’ve been around healthcare for more than 30 years. I have seen something as simple as an examination table cost more than $1000. In the course of my health care research, though, I became overwhelmed by the amount of data and the simple size of the task. Healthcare is a vast monstrosity. It is extremely difficult to get your arms around the whole problem. Therefore, it makes sense to me that we need to examine this problem in small pieces. Let’s look at the intensive care unit. In the intensive care unit, physicians practice some of the most advanced medicine that can be found anywhere in the world. Although I do not like to use case reports (anecdotes) as inspiration for action, they can illustrate a larger point.

Case 1: a 90-year-old gentleman was driving a golf cart on the road when he swerved to miss a car. The golf cart rolled down an embankment and the gentleman was thrown from a golf cart and hit his head on a rock. A witness saw this crash and called for an ambulance. The patient was awake and alert when the ambulance arrived and he was taken to the trauma hospital. The patient arrived at the trauma center complaining of a headache. The CT scan of his head revealed a small subdural hematoma (a collection of blood between the skull and the brain) near the temporal lobe. There was a small contusion (bruise) of the temporal lobe. The rest of the CT scan was perfectly normal for a 90-year-old gentleman. (This subdural hematoma does not require neurosurgical intervention.) At this time, the patient began having some language difficulties, was becoming a little confused and was admitted to the intensive care unit. Interestingly, the patient’s son was a pathologist. He was informed of his father’s condition. The next morning, per protocol, the patient had a repeat CT scan of his head. It was completely unchanged. Approximately four hours later, the patient’s mental status began to deteriorate. He was now having severe difficulty finding the correct words to express himself and was becoming agitated. At this time, the patient’s son came by for visitation. The son, extremely alarmed at the deterioration of his father, demanded that something be done. He informed the critical care physician that this patient lived independently was highly functional. The pathologist wanted a repeat CT scan. The critical care physician asked a few questions – what if the CT scan was worse? Did he want his father to undergo a neurosurgical procedure/surgery if necessary? How aggressive did he think they should be with a 90-year-old gentleman who was previously healthy? The pathologist, a physician, was unable to answer any of these questions. (Please remember that none of the patients presented here are real, but are presented to illustrate a point.)

What do you think should be done? Should we get a repeat CT scan emergently? Should we just keep the patient in the ICU (at a cost of $1000 – $1500/day) and watch him closely with continued IV fluids and supportive care? Should we transfer this patient out of the ICU to a regular room and institute “comfort measures?” (Case 2 tomorrow.)

Update: To continue with this case, the patient did undergo a repeat CT scan at the request of the family. The repeat CT scan was unchanged. Neurology was consulted. They came by and explained to the family that the patient’s symptoms were due to the bruise in his temporal lobe. It was unclear if these symptoms would resolve themselves or not. Over the next 24 hours, the patient’s symptoms improved and the patient was transferred out of the intensive care unit to a regular room. Over the next 48 hours, the patient continued to improve and was back to baseline. (He was walking, talking and eating without difficulty.)

I posted this case not as some sort of “miracle,” but as an exercise in thinking about end-of-life issues. How can a physician whose father is 90 years old not have some sort of plan with regard to end-of-life issues? If a physician cannot have a plan then what chance do the rest of us have?

Finally, I would like to address a sentiment that I noticed over at the Daily Kos (I posted this case there also) and also here on my blog, “hurry up and die.” If you read this case and you feel that the medical team was trying to push this 90-year-old man into the grave, you’re sadly mistaken. Instead, all medical teams should be weighing the risk versus the benefit of all therapies. A craniotomy in a 90-year-old has a survival rate of less than 5%. On the other hand, watching, waiting and evaluating turned out to be the right thing to do. By making sure that the patient’s blood pressure was adequate, giving the patient an adequate supply of oxygen and providing appropriate nutrition, the medical team put this patient in a position in which he could heal himself. What was the risk of a repeat CT scan? Not much. That’s why the medical team thought it was okay to order repeat scan. Yes, there was added expense, but it also put the family’s mind at ease. This is also important.

Tags: Healthcare // 4 Comments »

  • Brad

    As with all case studies, there’s not enough information. Adding information after the fact can make any comment look foolish (classic lawyer’s trick). However, here are a few thoughts:

    The fact that the patient is 90 is a non-sequitur. One of my grandfathers was far more vigorous, and a far greater asset to society at 90 than my other grandfather was at 80. The 90 year old did volunteer work with children and advised charities for almost 6 more years. The 80 year old was hardly vigorous and died at 81.

    The fact that the patient above was healthy and independent before the accident is only partially relevant. It only speaks to the possible benefits of care.

    Age, independence, and health condition are subtle ways of arguing about people’s “worth” or value.

    From an ethics point of view, that whole discussion is a non-starter. All individuals have the same inherent value. The only ethically fair way to solve “the lifeboat dilemma” (in the strict version: someone’s gotta go or everybody dies) is to draw lots or have everyone die.

    So, for allocating medical resources, the question is, “What good can they do?” Note that this is a very different question than, “Are they worth it?”

    The trauma surgeon is asking one of the important questions, which is essentially, “How does the outcome of further testing affect the decisions you will subsequently make?” If the answer is, “Not much,” then the testing is unnecessary.

    I don’t want to try to play doctor here, but let’s say the differential is that the guy is starting to stroke. Is the hematoma causing it? Can that be addressed? Is the bruising causing it? Can that be addressed? What do we need to know to answer those questions? Do we have a means for finding out?

    If we do, and it makes a difference, use it.

    Let’s say the differential is something else, call it “Thompson’s Syndrome,” and that generally clears up on its own, but sometimes needs a follow up treatment of some sort (doesn’t matter what it is — wet rag on the forehead, emergency surgery, whatever).

    In the event that follow-up treatment is needed, does response time make a difference? If so, does the ICU make more sense? (And by the way, a semi-private room for surgical recovery costs more than 1000-1500 a day; don’t ask me how I know).

    You went all Doctor on us about a year ago; I don’t want to go all Philosopher on you, but I’d recommend a look at John Rawls for two concepts:

    The first is the allocation of resource to those who need them the most. Note well that ‘need’ is a subtler concept than the vernacular definition. It’s not just a lack; it’s also the condition of being able to make effective use of the resources (which is where the partial relevance of previous health comes in).

    The second, which speaks directly to the discussion here is his concept of fairness: the fair way to divide a cookie is for one person to cut it in half and the other to choose the piece they want first.

    So, posit any health care system you want — single payer, corporate controlled, only available to a certain age — whatever, but when you wake up tomorrow, someone else gets to tell you what your position is in that system: are you rich, poor, young, old, hispanic, white, chronically ill, healthy, genetically vulnerable, whatever? You have no control over it.

    The designer cuts up the health care cookie, and everyone else chooses first. If the designer of the system would be satisfied with any part in it, then you’re getting a lot closer to a fair system than what we have now.

    Sorry to ramble on, but these are not medical questions; they’re ethical ones.

  • Elton

    My old friend Errington sees these issues from the perspective of the far end of life. I am a physician specializing in high-risk pregnancies, and I often take care of patients who’ve been told that the baby they carry has a serious medical problem. Many of the same questions occur: what to do for the baby while inside of the mom or after delivery? When should we offer difficult, complication-prone, expensive procedures? Who decides what should or shouldn’t be done?
    One huge problem here: the “designer” who could fairly cut up and allocate resources and distribute them based on appropriate need doesn’t exist. One of first things I have to determine when confronted with the clinical situation described above is who is the “designer” in that particular circumstance. Is it the parents, the insurance company, the hospital ethics committee, the congressman who created some law involved, the lawyer waiting in the wings to see the outcome?

  • http://www.whereistheoutrage.net/wordpress/about/ EC Thompson, MD

    thanks for your thoughtful insight. I appreciate it.

  • Linda

    Glad you are tackling these issues, Dr. T. Having recently gone through some of these questions with the death of my mother, I have a different perspective than I thought I would. I have realized that one’s days are never more precious than at the “end of life,” whenever that may be, and that we often don’t know exactly when that end will come for a chronically ill patient. For instance, does that mean all my mother’s care was “futile” for the last two years before her death (the Dartmouth Atlas Project defines it that way) because she was chronically ill? I certainly don’t think so. Those two years were precious, to her and me, and I think she “deserves” that care as much as, say, a 20 year old who later commits suicide. If impending death is the determiner of quality of care, then heck we are all going to die at some point so why bother? Why should age alone be the crucial criteria? My mother had a tremendous will to live, and that definitely kept her going for those last four months. She decided to have a tracheostomy, even with about 20 percent chance of favorable results, because she wanted that chance to get better. At what point do we deny her those odds? Because she is 72 and fat, but with a strong heart, when a 50 year old smoker with heart disease gets it? If we are going to ration care, why not in the NICU also?

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