An old medical joke goes like this:
An oncologist goes to check on his patient, a 90 year-old man with Alzheimer’s disease and metastatic pancreatic cancer. The doc is about to start him on a new round of chemo, but when he goes to the patient’s room, he’s not there.
He demands of the nurse, “Where’s my patient?”
“He took a turn for the worse and was transferred to the ICU. He looks like he’s reached the end.”
“My patients don’t just die!” he says as he picks up the bag of chemo and marches to the ICU. When he gets there, he asks the charge nurse where he can find his patient.
“I’m sorry, Doctor, but he’s gone. He was just at the end of his road.”
“But where is he?”
Thinking the doctor wanted to pay his last respects, the nurse told him, “Connell Brothers Funeral Home.”
The doctor picked up the bag of chemo, got in his car and drove to the funeral home. When he arrived, he marched up to the funeral director and said, “Where’s my patient?”
“He’s in the viewing room, sir.”
The oncologist marched into the viewing room with the bag of chemo, ready to hook up his patient…but the casket was empty.
“Where’s my patient?” he asked of the man in the suit.
“I’m sorry, sir, he’s in dialysis.”
Americans are, in general, people of faith. We believe in certain principles, such as freedom, liberty, and equality. Most Americans even believe in an unseeable, unknowable being in the sky. But there is one thing most Americans do not believe in—death.
Death is as foreign to Americans as sub-compact diesels, siestas, or socialized medicine. Anyone who works in a hospital knows that the intensive care unit is full of patients who should be dead. They are hooked up to breathing machines, kidney machines, machines to pump food into their stomachs, etc. They have a near-zero chance of meaningful recovery. Still, families often demand of doctors that we “do everything”.
But “everything” is a pretty vague idea. No one wants to feel responsible for the death of a loved one. If you ask someone, “do you want us to do everything or to let them die,” the answer will usually be, “do everything.” End of life issues need to be addressed early and often. We need to impress upon our patients that death is where we are all headed, and it can only be evaded for so long.
I had a patient once who had a history of kidney cancer. She was supposed to get yearly CT scans to check for recurrences. At the age of 76, she also had severe heart failure, but it rarely bothered her. Still, heart failure like hers carries a high risk of dropping dead. On one visit I asked her when her last CT for the cancer was. She said, “do you really think I need it?”
“Well, if you have cancer in there, the scan will find it. Removing it early can give you a lot more time.”
“Doctor, you do realize that I’m not going to be alive to worry about it, don’t you?”
No one likes to face mortality, but it’s still there. Part of health care reform must be “culture reform”. We need to remind ourselves that just because we can do something doesn’t mean we should. But how do we make these decisions? How do we decide to withhold dialysis from someone? Based on life-expectancy? Quality of life? Religious preferences?
None of these questions has easy answers, but other countries have some pretty simple approaches. They recognize that no matter how much you spend, no matter how much you do, everyone dies. The death can come at home surrounded by family, or in the hospital sucking up resourced for futile care. These choices aren’t really as hard as they seem. We have data to guide us, and quite honestly, if more Americans saw what goes on at the end of life in a hospital, we’d have a lot more empty beds.