Oh Henry
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Given that this issue of EPM is dedicated to sepsis, I’d like to address a question that was recently posed to me. Here’s the quandary: If EPs act early and aggressively they can make a difference in the outcome of sepsis patients. But many of these patients are elderly and sepsis may be their last chance to die of natural causes – pneumonia used to be called the “friend of the elderly”. Now we can intervene even more, pumping even more money into end-of-life care. When do I draw the line and say, “Yes, I could fix that problem, but the country can’t afford it”? Where is the balance between patient health and the health of the nation? Do we as physicians have a responsibility to maintain both?

First we must understand that the new treatments for sepsis are the old treatments for sepsis. Having recently reviewed most of this literature, the only two things that are really proven to work are relatively early antibiotics and adequate amounts of fluid. Most everything else is a hoax. All of the studies with steroids, new protein molecules and various central monitoring techniques are basically hype, smoke and mirrors to the nth degree. Give ‘em fluids and give ‘em antibiotics and hope for the best. But this is not the basis of the question being asked. At its heart, the question has nothing to do with the treatment of sepsis. It has to do with the maintaining of life beyond meaning.

There is no country with a national health program that does not have to ask serious questions about economics. As an economist, I believe that every activity in the world – from saving patients to eating dinner – has a price. At some point, we must recognize that what we are doing with many of our patients is prolonging death and not maintaining life. The comments occasionally made that it would be “playing god” to let certain people die are ridiculous. I would remind these docs that every time you practice medicine you are interfering with evolution, natural selection and survival of the fittest. At some point in time, we cannot afford to do everything for everybody.

Real leadership on this question is lacking. There will be no national health insurance program in the United States without financial limitations – name one country without them. The vast majority of European countries and the Canadians function under global budget restraints. Difficult decisions do have to be made. Any fool can advocate spending everything on everybody. It’s going to take someone with intelligence and true leadership to help make the difficult decisions as to what we will and will not accept. There is no health care program for everyone until there is a clear picture of where the limitations will be.

During the Clinton administration, the Clinton health plan died because it could not define what was NOT in the plan. People need to know what will and will not be done. Is maintaining grandma on a ventilator with no perceivable brain function an intelligent use of tax dollars? Why in the world would we maintain rotting flesh when those funds could be spent educating children, helping them become productive members of society? People who cannot understand the nuances of these difficulties have no business running for president of the United States.

On a practical level, emergency physicians need to give the issue of end-of-life care some serious thought, apart from the day-to-day immediacy of practice. The tyranny of the immediate will always force your hand. EPs need to think these questions through in a careful way and decide in advance what they will and will not do. Every day I talk with families about what they expect, what they think will happen and what they want done. And then I try to give them a realistic view of what is going to happen.

The end of life is death. It is a natural cycle. There is nothing that is born that does not die. So the question is: What are you owed by the society at large? A last-ditch-effort gastrostomy feeding tube? $5000-a-day ventilation for a respiratory patient? It’s not like we don’t have other uses for the money. Have you been to Detroit lately?

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and has directed an ED for 21 years. 
 

Comments   

# ed staff mdmike schankerman 2008-06-04 00:02
of course i agree with you, the amount of misspent resources astounds me, but the onus of deciding what should or should not be done cannot fall onto the physicians- we are busy enough figuring out what can or cannot be done. who's going to protect me when then vegetative grandma's son decides to sue?
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# Omar Lopez-Samayoa 2008-06-04 16:07
If the end of life is dead and all living have to die, should we treat elderly at all? Should we follow the law of the fittest? Would you like this law apply to you too? I believe a lot of the care should be done by the families not by the government. Your parents did not refused to change your dippers just because you could not do it. Don't you think now is your turn to do the same to them with love until they return to the dust? Just a thought.
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# EDMDJames J High 2008-06-04 19:49
I have been involved in EM since its earliest days and was involved with its development in the 1970's culminating in Board recognition in 1980. I have also witnessed and enjoyed Greg Henry.s contribution to the specialty.
However, I think this editorial,by him,should be read with caution, since there are those among us who might take the word literaly to mean, say, anyone over 70. At 70, I ran and finished the Boston Marathon. At 79 I had back surgery, developed sepsis with complications and survived with appropriate excellent medical care, fortunate that my physicians didn't decide for me that I had lived my alloted years or that a small bomb dropped on Sadr City would better serve the interest of the country.
I did recover and continue to practice medicine and am happy to be here.
Greg Henry should be listened to when it comesto EM Practice or EM medical malpractice issues. Ehical issues should be left to Ehthicist's,the specialists in life and death issues as they relate to other human beings
Jim (J) High FACEP FAAEM
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# Matt Underwood 2008-06-08 00:47
Thanks Greg for saying what needs to be said.
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# ED MDFred Hustey 2008-06-17 13:25
While there are some valid points presented in Dr Henry's article, it would be unfair and unethical to recommend witholding aggressive care based on age alone in the curent setting of our health care system. Certainly there are circumstances where providing aggresive care is not ideal. However, there is a distinction to be made between highly functional older patients (such as the physician above who ran the Boston Marathon at the age of 70 and returned to practice after an episode of sepsis) and those with advanced terminal disease (such as advanced dementia or end stage CHF).

Our health care system is riddled with problems. The amount of money we spend (and waste) is astounding. In spite of this, we are blessed with a system that does not force us to dictate who gets aggresive emergency care simply because we do not have the resources. We have the opportunity to consider each case individually. Based on many factors we often make difficult "life and death" recommendations to patients and families. When we begin accept over-generaliza tions dictating who should receive agressive care without considering all the facts, we sacrifice another aspect of the "human" side of medicine.
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# MDRachel English 2008-06-21 13:54
I think Greg Henry should be commended for saything things that everyone is afraid to say. Our country does need to start facing up to the reality that there is neither endless money nor resources to give care which is prolonging people's lives that are chronically ill, elderly, and have minimnal function. Just because we CAN prolong your life, does not mean we SHOULD. Our ICU's are full of Nursing Home patients who should be allowed to die when their time comes. It is possible that many of them would not want the care they are receiving if they were allowed to make that decision. We are all going to die someday. Dragging it out by another few weeks or months after living many years is not necesarily a good thing. Thank you Greg for speaking up. Rachel English MD
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# Septic Chambers of HorrorGravida Storm 2008-10-31 20:32
I'm glad Dr. Rachel English thinks people should be commended for saying things that everyone is afraid to say. Our country's medical establishment needs to face up to the reality that their crimes of medical education must come to an end, for the greater good.

Just because a first year resident "CAN" tell a patient she is a fourth year resident, in order to persuede the patient that she has expertise, does not mean that she SHOULD. An unsupervised novice's induction of labor on an unripened cervix can cause a patient's uterus to rupture; seriously endangering her life as well as her infant's, if he hasn't already died inutero from a birth defect. A 10-14 hour painful ordeal becomes 25 hours of extreme agony.

Just because an attending "CAN" abandon a patient who's been in labor for 24 hours, after the patient has ordered the resident to leave because she has begun to fear for her life and has demanded the resident get the "REAL" doctor, does not mean that he SHOULD walk away, even if HMO patients are "only 20 cents on the dollar."

Just because two residents and their 16 medical students "CAN" ambush a woman in childbirth, as she is crowning does not mean that they SHOULD. Labor and delivery wards nationwide are full of victims of this heinous act. A woman delivering an infant (dead or alive) should be allowed to decide whether or not she wants to undergo this event while 16 medical students and two residents watch her infant emerge. She cannot fight. She cannot flee. She cannot speak. The trauma they inflict causes harm. Many of these victims would not want to be ambushed as they are crowning if they were allowed to make that decision. And that decision would not deny medical students opportunities to train because many women, if asked, will allow at least one or two and occasionally the entire rotation.

Just because a Hell bent nurse "CAN" change a trumatized patient's bloodied gown in front of 16 medical students and two residents (further traumatizing her) does not mean that she SHOULD. Nurses are supposed to be the advocate of the patient, not medical education.

The United States of America is a democratic society and democracy must prevail when it comes to patient's participation in medical education. Medical rape is a virulent sepsis that continues to infect because the policing mechanisms of the medical establishment willfully allow it to. Their survey teams are well aware that these crimes are occurring in many hospitals they survey because most of them received their medical education by committing the same heinous crimes. Their traumatized victims are left speechless. It's time that someone gives their victims a voice. Thank you Rachel for opening the door.

Gravida Storm
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# UnderstandCindy 2011-05-01 02:57
I totally understand what he is saying. My grandmother is in the hospital with sepsis now. Her quality of life is terrible. She is in a great nursing home, but she can no longer use her arms to even scratch her nose. She is in a diaper and a catheder and cannot walk. She has her mind, but is trapped in a body that doesn't work. Who wants to continue like that?
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