Just because we can doesn't mean we should

Published on December 8, 2005 By BlueDev In Health & Medicine

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?

Comments (Page 2)

BlueDev

on Dec 09, 2005

Am I worth it??I doubt it.

I don't think it is a question of is the patient worth it. Everybody is worth it.

But there are simply some times where pushing it is the wrong thing to do. This will sound incredibly arrogant, but it is one of those things you have to be there and have experienced to see. There are always cases like yours Trudy. But there are also many cases where the patient was miserable after all that was done and regretted it all. Only those of us in medicine get to see them both.

ParaTed2k

on Dec 09, 2005

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...

The fact you lived to do all these things is proof that whatever measures were taken were well worth it. The point here is (if I understand it correctly), the resources should be used for people in your situation, instead of being wasted on those who the best we can offer them is a beating heart, and a boatload of treatment to do little more than keep the person oblivious... just so we can look at the family and say "we did all we could do".

BlueDev

on Dec 09, 2005

The point here is (if I understand it correctly), the resources should be used for people in your situation, instead of being wasted on those who the best we can offer them is a beating heart, and a boatload of treatment to do little more than keep the person oblivious... just so we can look at the family and say "we did all we could do".

Yep, no question you understand it correctly.

Dr Guy

on Dec 09, 2005

Yep, no question you understand it correctly.

And from the outside, I dont want to make that decision. I think that is what she is saying.

BlueDev

on Dec 09, 2005

And from the outside, I dont want to make that decision. I think that is what she is saying.

I don't blame you Dr. Guy. I think a lot of people on the 'inside' don't want to make that decision. It is difficult and requires a the doctor really communicate with and understand/empathize with the patient and their families. But it needs to happen more often. Both sides need to understand each other and be willing to face and accept these difficult decisions.

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