If physicians can’t give sound end-of-life advice to patients and families, who will?
The principle issue in this country today, with regard to medicine, is not any particular form of research. It is not any particular operation. It is what are we going to supply to elderly people where there are limited resources and a shrinking base of people to pay the bills. This is more than symbolic. It is a day-to-day problem which no one seems able to deal with in any realistic way. And no one sees this dilemma like emergency physicians. The average emergency physician will spend a third of their time on any shift dealing with people who are in stages and conditions of their life that we can’t fix. People are sent to the ED for reasons which boggle the mind and break the bank. We have no idea why we are about to apply technology in any particular way or form. Let me give you four scenarios which illustrate this all too well.
The first group is the nursing home shuffle. These are patients sent to the emergency department with some unusual note or comment saying, “Patient worse than yesterday.” The real question is, “Worse than what?” Were they algebraically proving the Pythagorean theorem the day before and now cannot remember the date, have food stuck on their face and suffer an impacted bowel? None of these things are emergent questions, and yet they continue to come in. This is the mere shuffling of the near dead. Questions are asked by everyone: Did you work them up for this? Did you work them up for that? My usual answer is, “Not a chance. They were bad before they came in. They are bad now.” A specific complaint, like “fell out of bed and broke a wrist,” I can handle in the emergency department. The long-term trajectory of their life, I cannot. These are social and emotional questions which the emergency department is not properly set up to handle. Don’t get me wrong, non treatment or non evaluation is not the same thing as not caring. I think we need to care properly for individuals but we shouldn’t pretend – to either the patient or their family – that we can reverse the ravages of time.
The second group is the holiday visit attack squad. This is when you have grandma brought in by family members on Thanksgiving evening. They haven’t seen grandma for six months but now she suddenly looks worse. No, she’s not worse. She’s just been going downhill. The fact that her dementia is no better, the fact that she sits aimlessly starring at a TV and makes unintelligent comments should not come as a shock to family members, but it always does. They rush in thinking there must be something obviously wrong that we can fix. Now, dear reader, don’t lie to me. I know what you do. We repeat the basic metabolic panel. We check their hemoglobin and we make sure they are not bleeding from the rectum. But everything beyond that is a shot in the dark. Six months earlier they had early changes of cortical atrophy on their CT. Are you going to do another CT? The patient has no focal findings and no evidence of trauma. What are you going to find on that CT that is going to change the trajectory of this person’s disease? We are the only country on the planet where we do the same things over and over again expecting a different result. In most places, this is considered to be insanity, but here, it is called thorough medicine and it’s financially, morally and intellectually killing our country. It does not allow families to come to grips with the natural progression of life or death.
The third group is the one we’re likely to see the most. This is the do-gooder neighbor. These are wonderful people who are watching grandma everyday. But again, they seem to think that minor changes one way or the other are clearly a change in direction. The best thing we can do for do-gooder neighbors is keep them coming in for care, but keep them out of evaluation and treatment decisions. I remember one woman who presented with her neighbor. She had a list of drugs she wanted me to start her on because it was her opinion these were basically “good for what ails you.” She wanted a 91-year-old with near end-stage dementia started on Lipitor. Why would you give a patient a drug that costs a thousand dollars a year, which has never been shown to change long-term outcomes on anyone except those who actually have had a myocardial infarct? Her demand for B12 shots and cod liver oil fell on relatively deaf ears as well. I made her feel good about the fact that she was giving her neighbor wonderful care, but this involvement in the day-to-day medical management of patients should be a technical question and not a societal free for all.
The last group is the one that depresses me the most. They are patients cared for by the doctor-as-medical-opportunist. One of the last patients I saw last January was a woman who had end-stage congestive heart failure, as well as dementia and end-stage renal disease. She had been in the hospital nearly a week before. I noticed a large surgical scar running from the area behind the pinna of the ear down toward the collar bone. I asked what this represented and she said, “Oh, the doctors found a small mass and wanted to have it removed to make sure it wasn’t cancer.” Just as the EMTs, as usual, start CPR on a patient that is essentially begging to die, I had to look at this with amazement. Why would a physician take a patient who has three end-stage diseases and perform a procedure that was both expensive, required multiple other physicians to review the histology and was in no way going to change the patient’s long-term outcome? My frustration with this has reached the boiling point. If physicians do not provide direction to patients and families, who will? When are we going to get to the business of understanding when our interventions make a meaningful change in the outcome of humans and when they won’t? When are we going to finally decide that enough is enough?
Greg Henry: Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.