This month EPM focuses on geriatrics. Geriatrics should not be taken as merely a small subdivision of emergency care within the larger health care question. No, it is the fundamental issue of our time. How we handle the elderly essentially defines who we are. Leadership in this arena has been seriously lacking since the end of the Second World War. No president, democrat or republican, has had the courage to carry on the national conversation which is necessary to decide what we are going to do as we age.
Science will never answer this question. Science is neither moral or immoral. It is amoral. It is always good to remember that the scientists who built the gas chambers at Dachau were perfectly good at science. They were just perfectly bad at philosophy. Similarly, what we do in medicine is a science question. Who we treat and when we treat are philosophical questions. And philosophy must lead the science where the society wants it to go. What leads us is more important than who leads us on this issue.
The geriatric healthcare issues which are set before us constitute – depending on what you include in the pile – 75% of the US expenditure in medically-related issues. The elderly consume about 85%, on a cost basis, of all the medications produced in the United States. The use of X-rays and CT scanning goes up logarithmically with age. And, no one likes to carry on the conversation that as we continue to spend, the return is less and less. Just the geriatric portion of health expenditure is now the largest single industry in the world. It is the principle expenditure of the federal/state government, larger than defense and just ahead of the looming giant of the interest on the national debt.
I believe that the issue in front of us is to separate out two entirely different practice questions. The first one is the science of medicine; the second is the science of care. I never believe that I have nothing to offer a patient. I always have something to offer every patient. But we should understand that at a certain point in time what I have to offer is comfort and care and not necessarily intensive application of diagnostic and therapeutic science. These two approaches have almost nothing to do with each other.
On my last shift I saw an 87-year-old gentleman sent from the nursing home. He lives at the home because he is demented. Essentially the family, including his wife, are waiting for him to die. Why was he sent to the emergency department in a somewhat dehydrated condition? Is it because we’re afraid to let people die in nursing homes? Is it that we feel so guilty about the way he’s been handled throughout his life that now, at the moment of death, we must go through ridiculous rituals which have nothing to do with extending any meaningful life? This primitive tribal ritual of beating on chests and inserting tubes and wires can only be considered barbaric in the extreme.
If you’re wondering how I handled this demented patient, I’m happy to tell you. I gave him three liters of fluid, he perked up a little bit, he appeared to his wife to look as he usually did, and sent him back to the nursing home. There was no way that I was going to put this gentleman – who had lived a full and productive life – through ridiculous hoops in the end. He could not identify his wife when he left, but he couldn’t identify her the day before, or the day before that. He was no worse off than he had been. To have repeated a CT scan of his head – which had been done only a few weeks before – and to do a huge metabolic work-up in someone who is demented and somnolent on the best of days, is to belittle his dignity and to deny reasonable assistance to his grandchildren and great-grandchildren who are in true need of services.
If President Obama truly wants to lead, if he desires a “health care fix,” then this is where he needs to go. The national conversation needs to decide what health care we are going to give out and to whom. Until we realize that we can’t do everything for everyone and there needs to be some rational rationing of care, I’m afraid we are destined to crucify our children on the altar of the expanding national debt.
Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.