A silly little blog for me to drop the excrement of my mind.
Medical miracles occur daily. People are alive far longer than the could have been even just a few years ago. Diseases that were death sentences in the memory of many who may read this are now thought of as minor speed bumps in life. The volume of new medical knowledge is amazing, and the unexplored horizons seem even more vast than they did prior to this explosion of understanding.

With this knowledge has come the ability to stave off Death. This dark and minatory specter still lurks, but often from a greater distance than in the past.

But at what cost?

And I don't mean an actual, monetary cost (that is the subject of another article). Rather, what cost to the patients, their families, the physicians and medical system as a whole, and even to society?

Let me provide an example.

Let's say the patient is a 70 or so year old male. He has lived a pretty good life, has a happy family, retired from a job he mostly enjoyed. But his heart isn't doing well. And it isn't just coronary disease, but this gentleman actually needs a heart transplant. The day comes, and he gets one. Of course, it is a large, potentially fatal surgery. But he pulls through. He does have to go on ECMO for a time (extracorporeal membranous oxygenation) because the new heart just can't keep up at first and isn't pumping the blood where it needs to go sufficiently. But on an adult sized body ECMO isn't sufficient either, and there is some end-organ underperfusion (namely, the kidneys just don't get the blood they need, and kidneys need a LOT of blood). The patient progresses and is able to come off ECMO. However, the kidney damage was final, and dialysis is started, at least three times a week to keep the electrolytes balanced, perhaps every day to help fine tune the patient's volume status.

For those who don't know, dialysis is usually around 3-4 hours a day and is often quite exhausting for the patient. But this patient is one of the successes and is discharged after a month or so in the hospital. Thanks to the marvels of modern medicine, the patient heads home with a new heart. The patient also heads home with a bag full of medications, some to suppress his immune system (making him more vulnerable to the infections we all encounter every day, but fight off without batting an eye lid), some to carefully manage blood pressure so as not to strain the new heart (some of which make the patient dizzy and prone to falling/passing out when he stands), some heart medications that prevent the heart from beating too fast (and also can accidentally lower the heart rate enough that the patient passes out). The patient also has to schedule at least 15 hours a week for dialysis (to allow for transport, setting up the machine and 3-4 hours a session with the machine actually running), after which he doesn't really feel up to much else for that day. Slowly, the patient may recover some of his strength, though there is no guarantee. And the number of years that this will extend his life is entirely unknown, though likely not that long.

So what have we really done? Have we improved the patient's life? Maybe in his mind, yes. Maybe. But much of the time the answer is no. Far too often we extend life and extend life and extend life. The entire time, we do nothing for actual living. People's lives are reduced to "Which appointment do I have today?" followed closely by "What pills do I take now?" and other similar questions.

Just because we can, doesn't necessarily mean we should.

Who is to blame though? Well, we all are. On the whole, humans just seem to be scared to death of Death. We run from him at every chance and forestall the inevitable. We demand the latest life-prolonging technology. Advertisers shove these advancements down our throats, and the wonderful internet gives us just enough information to be dangerous. Doctors are humans to, and have that same societal fear of death. Too many have never learned how to tell someone there is nothing more to be done while still caring for the patient. They fear the reaction, and so they offer false hope through possible procedures and pills. The litigious nature of our society does nothing to aid this, creating an environment of anger and suspicion. Doctors can no longer tell a patient "We have done the best we can, there is nothing more to do now," simply because there is always something more that could be attempted, and they don't want the lawyers swooping down on them. And so we continue. We expend valuable, limited resources on fruitless cases. People watch their family members suffer and wallow for years instead of days or weeks because medicine can do just enough to keep them alive, but not enough for them to really live.

We did it because we could. But I have to ask, should we really have done so?

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Comments (Page 1)
on Dec 08, 2005
Oh the awful memories I'd just as soon forget!

The memories of puffing and sweating during CPR between 360 joule shocks, Epi injections, running a code on a 70 year old patient. Feeling the ribs break and the sternum seperate. Squeezing oxygen through a bag-valve mask into lungs so full "musous plugs" we might as well be trying to push the air through oatmeal. Why? Because 1) We can, 2) No DNR and/or 3) so when the patient does die we (or the ER doctor) can look the family in the eye and say "we did all we can do".

Or picking up your heart transplant for those thrice weekly visits with the dialysis machine. Usually feeling sick, tired and weak as we pick them up... and feeling even worse on the trip back. Hoping that they'll have a good day on their "off" day... when they enjoy a few hours not filled with hacking coughs, vomiting or scorching fever from some infection they picked up along the way.... and let's not even get into the wonderful world of MRSA.

I agree with you, modern science can (and should) do wonders in the fight against death... but there are patients whose life is death... and we're not doing them any favors.... but the Doctors, Nurses and Paramedics can feel better because we do "all we can".
on Dec 08, 2005
I agree with you, modern science can (and should) do wonders in the fight against death... but there are patients whose life is death... and we're not doing them any favors.... but the Doctors, Nurses and Paramedics can feel better because we do "all we can".


Ted: Thanks for sharing your insight. It is a difficult question, for sure. But we MUST get to a point at which we can say that doing more is the wrong thing. And with some patients that needs to be before we have done literally everything possible. Thanks again for the comment.
on Dec 08, 2005

We did it because we could. But I have to ask, should we really have done so?

Good question, but then you already know the answer.  As long as we can, we will.  Should does not enter into it.  But thanks for a very scary look into a possible future.  SHould I be placed in that position, I will just go home to die among friends and family.  I would not want to live like your example.

on Dec 08, 2005
Good question, but then you already know the answer. As long as we can, we will. Should does not enter into it.


But it must enter into it.

I ignored the economic aspect, but let's factor that in here. Millions, even billions of dollars are spent every year on cases just like the ones Ted and I presented. In other words, billions of dollars that could be used to help improve the quality of life for millions of people who can then turn around and help others. Granted, not everyone who could be helped will then help others. But people fail to realize the strain that these rather hopeless efforts put on the system and the numbers of individuals whose lives really would benefit from these resources.

It is a hard and perhaps even cruel question to answer. But at some point we need to be able to say enough is enough. And that needs to be before we have exhausted every single possible resource.

But thanks for a very scary look into a possible future.


Happy to do so, because if people were more educated as to the probable outcomes of many of these interventions they would be more likely to make the same choice you and I have: call it quits, head home, and pass on with my loved ones close in a place I know and love.
on Dec 08, 2005

I ignored the economic aspect, but let's factor that in here. Millions, even billions of dollars are spent every year on cases just like the ones Ted and I presented. I

When you factor in the money, it is a whole nother egg.  Should still does not enter into it, but the ability to pay does.  I am not saying Should Should not enter into it, I am saying no one is going to make that call (other than the patient). And sometimes, that 70 year old (or 59 year old) is doing exactly what you want.  Remember Barney Clarke?  before trying an experimental procedure on someone who has perhaps many years to live, others, with absolutely no hope, can be used - with their permission.  Again, the cost of Barney's procedure was outrageous, but it helped to figure out if Artificial hearts were viable.

on Dec 08, 2005
Good question, but then you already know the answer. As long as we can, we will. Should does not enter into it.


Actually Dr. Guy, ther are already times we do put "should" into the picture. In a mass casualty situation (such as a huge car accident, or an industrial toxic leak), we use a system of "Triage" that identifies people by their likelihood of survival. The more likely they are to survive, the more attention they get... and vice versa. We don't carry the dreaded "Black" triage tag in our ambulances to be politically correct.

It wouldn't be that far out of the bounds of humanity to include the protocols to other life threatening situations... choosing recipients for organs for example.
on Dec 08, 2005
I'm sure patients have a myriad of reasons for wanting to undergo these procedures, but I also think that they all come down to one central theme: wanting more.

More time with their family, more time to pursue their hobbies, or even just to see more of the changes that occur in the world.

I've come to the realization that regardless of when one dies, the desire for more will always be there. I don't think anyone truly lies on their death bed thinking, "Well, I've had a good run, but it was enough." I do tend toward risky behavior, such as being more bold about stepping in front of traffic that hasn't fully stopped for a red light, or snowboarding at speeds on the razor's edge of control. But this thought came second, knowing that I will continue to behave in this manner not in spite of the risk, but on account of it.

On that note, I found a pretty cool article yesterday about living indefinitely, although it's rather vague on the specifics, and I haven't had time to delve further.Link
on Dec 08, 2005
I am not saying Should Should not enter into it, I am saying no one is going to make that call (other than the patient).


Gotcha. My misunderstanding.

I suppose I see it from the position of being there when someone beside the patient made the decision, and it was an enlightening experience.

Rather young patient, incredibly ill. More sickness than you could really even consider. I was called to see the gentleman as a Nephrology consultant. I walked in the room and honestly thought I was looking at a dead man. The MICU (Medical ICU) attending was rounding with his team and this patient was being presented by one of the residents. Were there still things that could have been done for the patient? You bet. We could have dialyzed him, we could have hit him with numerous meds, we could have rushed him to the OR. And the resident, trained here in the US with this sort of 'do all' mentality, was proposing such action. The attending actually had some balls, interrupted the resident and informed him that they were going to tell the family that there was nothing more that SHOULD be done. The resident balked at this, visibly upset, and said "We can't do that here in the US!"

The attending calmly, but forcefully responded "Yes, we can. And you better start learning how to do just that. We will do nothing more for this patient other than ensure his comfort."

I was inspired. Physicians can make those sorts of choices. I believe they should carefully do so more often.

If a person is full code, then yes, we code them. But I am really arguing that we do too much in many instances before the patient actually gets to the code. And doctors can and should educate their patients, but also tell them "No".
on Dec 08, 2005

Actually Dr. Guy, ther are already times we do put "should" into the picture. In a mass casualty situation (such as a huge car accident, or an industrial toxic leak), we use a system of "Triage" that identifies people by their likelihood of survival. The more likely they are to survive, the more attention they get... and vice versa. We don't carry the dreaded "Black" triage tag in our ambulances to be politically correct.

But you have again introduced another factor into the should arguement.  Yes, in that situation, you have to make judgement calls based upon limited time.  IN the case that BlueDev described, that was not a factor.  I do remember the MASH episode where Blake asked pierce to consult with him over a case that would not make it.  But then the decision is not "should" in that case, but how many are saveable, and how many are too far gone.  The question changes then.

on Dec 08, 2005

The attending calmly, but forcefully responded "Yes, we can. And you better start learning how to do just that. We will do nothing more for this patient other than ensure his comfort."

That is why you make the big bucks (or at least he does).  I do understand, but I would never want to make that call.  I can empathize with both the resident and the attending in that case.  You are right, sometimes, doing nothing is best.  But it is also the hardest thing to do.

on Dec 08, 2005
But you have again introduced another factor into the should arguement. Yes, in that situation, you have to make judgement calls based upon limited time. IN the case that BlueDev described, that was not a factor.


Actually Dr. Guy, I didn't introduce anything new... I only extended the "judgement" we use in triage to other areas, using the same criteria... namely "likelihood of survival. btw, time isn't the reason we triage, limited resources is.
on Dec 08, 2005
But it is also the hardest thing to do.


It absolutely is. And that is one of the times I truly believe in the 'art' of medicine.
on Dec 08, 2005

btw, time isn't the reason we triage, limited resources is.

Time is a resource. and one that is hardest to augment.

on Dec 08, 2005
Time is a resource. and one that is hardest to augment.


Put that way, you're right. It is also one of the reasons we do leave the "black tags" for dead... it buys more of the "golden hour" for the others.
on Dec 09, 2005
15 years ago next month, I had a mild MI due to a dissection of my LAD. I was hospitalized 13 days, had an angiogram
and put on multiple medications.
A follow-up stress test, without the heart and blood pressure pills, caused chest pain and at the cath lab they discovered
that I also have Prinzmetal's angina!
So Isosorbide was added to the mix.
I've now had 2 mild MI's due to dissections.....have cost the taxpayer's thousands of dollars........
I'm on 4 kinds of heart meds, and Methotrexate for the RA..
Am I worth it??
I doubt it.

Do I appreciate it?
With all my heart.....
I"ve lived to see all 4 of my grandchildren, lived to see my son graduate from highschool, get to teach him how
to fish, lived to try to help him get through life with his disabilities, ( if I had died he'd have been in foster care
for at leat 4-9 years)
and cherish every sunrise, even though some days I feel blue...

How will you and others decide who gets to live??????
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