We spend on end-of-life care at expense of patients

I have an elderly, demented aunt in California for whom I am the responsible decision maker. Up until a few years ago, Aunt Doris was an intelligent, powerful, and forceful woman. Picture Nurse Ratched in One Flew Over the Cuckoo’s Nest and you will be pretty close, although Doris was never so insidious. After a stint as an Army nurse, serving near the front in the European and Philippine campaigns of WWII, she was a head nurse in the VA psychiatric hospital outside San Francisco for 20 years. Ken Kesey was an orderly there for a year before writing Cuckoo. In typical Doris fashion, when I asked about him, her summary was “Good for nothing, lazy SOB.”

Every night I see scores of exams on elderly patients. Last night I read an unenhanced head CT, perfusion scan, and CTA head/neck on an 80+ patient. The clinical summary given was “history of dementia, confused tonight.” Three thousand dollars to prove the brain looks like a hybrid of Swiss cheese and a dried walnut.

If we are ever going to control healthcare costs, people will have to accept that dying is part of our life cycle, and those in authority will need to incorporate this understanding into our healthcare system. Doris, when she was lucid, understood this well, and did everything possible to document that she wanted to die in peace, not in an ICU bed with tubes in every orifice and vessel. And still, the system works against her.

We enroll her in hospice with a failure-to-thrive diagnosis, but if she gains any weight, her insurance company takes her out of hospice. Then she gets sick again and is transferred from the nursing home to the hospital and treated intensively until I can contact her doctors and explain her wishes. She goes back on hospice and the cycle starts again. Recent changes in California law may be ending this cycle, but very few states have significant laws related to-end-of-life options.

Why does our system make dying so hard, and why can’t we fix it? Like most tough questions, the answers are complicated. Our culture has made discussions of death difficult for doctors and patients. Some religious and political groups view such forums as death squads. I guess the logic here is, if we don’t talk about it, it doesn’t happen. Sounds like the military’s “Don’t ask, don’t tell” policy.

Financial factors also play a significant role. In the span of my lifetime, American healthcare has evolved from a profession based on personal relationships into a behemoth modeled on a corporate structure. While corporate America likes to espouse noble ideas and goals, the bottom line always wins. One third of Medicare expenses come in the last two years of life, about $66 billion a year. Hospital organizations know imaging and high-tech surgery/procedures are the golden geese, so how hard will they lobby for limits? Ditto equipment manufacturers. Publicly held companies and private investment funds are becoming major players in radiology. How much do you think these large, for-profit companies will spend lobbying Congress to rein in medical expenses, and bring rational limits and decision making into end-of-life care?

For years I have felt our nation needs an Oregon-style Death with Dignity law. Recent experiences with my Aunt Doris have only reinforced that belief. As a radiologist, I am on the receiving end of the current situation, but as a physician I see the waste, futility, and near cruelty involved. I support organizations like Compassion and Choices, which work to change this mess. It remains to be seen if corporate medicine will support such a concept, and the hit on their bottom line. I suspect they will sit back and ride the status quo all the way to the bank, while doctors and patients remain frustrated here in the cuckoo's nest.