Brian Lehrer
Does money legitimately come into play here, ever? Does it come into play in ways we're not addressing?
Kenneth Prager
You asked two questions: Does money come into play? Does it legitimately come into play? I'll answer the first question first. Yes, money comes into play whether on a conscious or subconscious level. I think that, given the crunch that hospitals are feeling across the country in terms of their budgets, in terms of the difficulties that hospitals encounter with managed care and reimbursement, hospitals are going to react negatively if they see their intensive care units populated by people with minimal chance of leaving the hospital, people who are being kept alive on ventilators. That message will filter down one way or another to the people who are responsible for the care of those patients. You asked if money legitimately comes into play. I think that it is a legitimate concern. It's a legitimate ethical concern, because I don't think that we have an unlimited budget for medical care and we don't have unlimited facilities. In a particular hospital, it may not make a major difference, but, countrywide, somewhere or other we are going to feel the pinch if tremendous sums of money are spent on patients who have, say, minimal chance of survival to discharge. Programs will be endangered. I'll give you an example. At our hospital we have a program of heart transplantation. It's a very expensive but a very wonderful program, and there are patients who, in transition to heart transplant, are placed on what is called an LVAD, left ventricular assist device. It's a very resource-intensive intervention, a very labor-intensive intervention. The problem arises really with a patient on an LVAD device who is not a candidate for heart transplantation because of supervening medical complications: how long can a patient be kept alive on this device? Now, it's fine to say just keep him alive until you can no longer treat him. But if the program did that it would cause such financial hardship to the hospital as to bring into question the financial viability of the entire program. That would mean lives lost because people couldn't get transplants. So these economic questions have real ethical and medical applications.
Tikva Frymer-Kensky
I think that's absolutely true. We don't see it because it's all diffused and impersonalized. But with a population that's growing and a limited amount of dollars, we're in a lifeboat situation, and at some point either everybody starves or you start rationing, and you triage. In conditions of triage, we might say people in persistent vegetative states cannot be kept alive at this hospital more than six months in that state--at that point we will no longer treat them.
Brian Lehrer
Dr. Mayer, do you ever think about that when you're treating an individual patient or communicating with their family?
Stephan Mayer
No. In a global way, if there were better guidelines I think it would be good, but the practical reality, at least in the United States now, is that we have the luxury so far of never having to think about the economic issues. We just don't. There's no reason to. We don't have our act together enough to make these issues. We have the luxury of dealing in a more perfect theoretical world where we're just trying to do what the patient wants and what the family wants.
We'll get situations where all the ICU beds are full--this happens every winter--and there may be several specific patients in some of these beds who are not going to benefit by staying in there. But the family insists. On top of that, the patient clearly wouldn't want it anyway, but the family doesn't want to give up, they feel guilty, they have a hang-up. And then you have the next patient roll into the emergency room--a young person, with something they can recover from, but they've been intubated, they're on a respirator, and where do you put them? And this creates a kind of a triage. What will happen is, this patient may be in the emergency room, sometimes, in our hospital, for as long as a day or more, and for the critically ill, that setting is not where you need to be. That puts that patient's life at risk, because there's only so much resource. Kenneth Prager
Let me just reinforce what Stephan said. When I answered you before, Brian, I didn't mean to imply that this is actually taking place today--you've reached the one million mark, you're out. It doesn't happen that way, but I think it's going to be more and more of an indirect consideration as the years go on.
Brian Lehrer
I got what I considered a shocking letter from my HMO a few years ago. It was just a form letter that they probably sent to the tens of thousands of people who were insured by them, but it was to remind me that I had the right to make a living will or other document that expressed my end-of-life desires. Now, that's all they said, but you know what the subtext was.
Kenneth Prager
Did they encourage you to reject all treatment?
Stephan Mayer
But getting back to where we are now in the United States: given the limitation of resources, my feeling is that the real place to start again is with the fact that many patients are having these high-tech deaths that they really don't want anyway, and we're just reluctant and slow to face the implications. If we're not going to keep pounding away on the patient, which is what we call it, then what are we going to do? Some hospitals have pioneering pilot projects where they've got a palliative care team. Once the decision is made with doctors and families that we're going to change the goals of care, this team swoops in. They've got counselors, they've got clergy, they've got a game plan: This is what we're going to do. There's a special section in the hospital we're going to put the patient in, and I think that improves the level of care and makes it easier to make that decision. It gets back to really listening and respecting what the patient would have wanted.
Kenneth Prager
I'm just going to disagree with Stephan a bit to inject a little controversy here. I don't think that that is as much of a problem today as is often touted to be the case, at least in the ethics consults that we do. Physicians flagrantly going against a patient's expressed wishes even to their relatives--I just don't see it all that much. I think we're getting much better at limiting. I think the problem is that, in cases where patients have not made their wishes known and because of our increasing technical sophistication, there's always a ray of hope. Now, that ray may be very small, but it's there, and I think that this keeps things going in many cases beyond the point where it's appropriate.
Brian Lehrer
How fast is technology changing the nature of this whole discussion?
Kenneth Prager
Tremendously. I've been at Columbia for 27 years, which seems, I guess, like a long time, but it's not a long time. And it's night and day. Just in the past five or six years there have been developments in intensive care, surgical techniques, pharmacologic drugs and so forth. Take the treatment of AIDS, for example. I'm old enough to have been a physician when AIDS first came on the scene in about 1982, and it's a totally different disease today. It's gone from a disease that killed people within a few months of diagnosis to a chronic disease where, when you take the appropriate medications, you can live for 10, 15 or more years, like with diabetes or coronary disease, and other things as well. It's similar to the revolution in cardiovascular disease and transplants and assistive devices and so forth. Now all of these kinds of patients eventually do get into trouble, and there's always one more chance of keeping them alive a bit longer, even in the treatment of cancer. Chemotherapy of lung cancer, which is my field, is much better today than it used to be. Patients who used to be considered hopeless are now given options. So, again, I think that the technology is always a few steps ahead of the societal values and our ability to cope and decide what to do with this technology. And it seems to be continuing at that pace.
Brian Lehrer
Have you seen that on the front lines in neurology?
Stephan Mayer
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| Thinking Point | |
| How have developments in technology in the last ten years affected the treatment of patients who would once be considered terminally ill? List three ways new advances have impacted end-of-life decisions. | |
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Oh, absolutely. The people we used to get, in a comatose state with a brain aneurysm, were until very recently written off for dead. We're now aggressively treating those patients and, amazingly, sometimes they do well--not always, but sometimes. And what about elderly people who were written off before? I mean, the envelope keeps getting pushed. Brian Lehrer
Doesn't that present you with new kinds of dilemmas in terms of who lives and who dies?
Stephan Mayer
It's an ongoing dilemma. Now we're confronted with these kinds of issues, particularly when we take an aggressive approach to give somebody an honest chance. We say to the comatose brain-injured patients, "We're going to give you a one-week trial of the full-court press. We're going to give you everything, even if it looks quite desperate." And my practice has been to start working with the family right from the beginning. We say, "I'm going to be able to look you in the eye and say to you that we did absolutely everything." In fact, sometimes other people in the care team may roll their eyes and think we're going too far. But the idea is that in a week we're going to see where we're at, and if the patient seems to be getting better, and if that ray of hope is widening, great, we'll keep going. But if we really give it the full-court press and it's clear after a week that we're not going to get a good outcome, no way no how, we tell them to be prepared about what the next appropriate step might be.
Basically, you can keep the brain-injured patient alive, but that involves putting in a tracheostomy tube and a feeding tube, and the plan is that the patient is placed in a nursing home, and there you are. For some people, that's not their cup of tea. So when we get to that point where we tell them we have to decide if that is going to be the plan, the other alternative is to say we're going to pull back, we're going to stop the machines and switch the goal of care to comfort.
Brian Lehrer
Do people in hospice have to be up on all this, or does your role come once those decisions have been made?
Julia Quinlan
I would say that, once the decision has been made that the patient cannot survive, that the patient is going to die, then we just do palliative care, which is just to make the patient comfortable. Because the hospice is Medicare-certified, the doctor must state that the patient has only six months or less to live in order for the patient to be admitted to the hospice program.But the problem is that patients associate hospice with death.
We have established a transition program where we can care for a patient for a year or a year and a half, and then, as their condition worsens, they can just make the transition into the hospice program.
Tikva Frymer-Kensky
We are making strides. Just a few years ago, when an approach like the one you describe would have been impossible, people would say they had relatives in this situation and the doctors would say, "If we try this, we can't ever withdraw it, so we'd better not try it, because it might not work and then we're all in a legal bind." And that was a terrible thing, because people didn't try when they had a chance, and so I think that there is a real advance on that issue. Now we can try as long as we think there's a ray of hope that's reasonable, and then say, "Look, we did all we could reasonably do." Now we have to change the mode of care and the goals of it.
Brian Lehrer
Well, we're almost out of time, and I'm curious where each of you think this discussion will be in 10 years. Dr. Mayer?
Stephan Mayer
In 10 years. I think we will have come a long way, I really do, and I'm very encouraged by the kind of progress that I've seen at our institution and at others and in talking with colleagues. I'm not sure exactly what the issues will be in 10 years, but I think we're going to be a lot more enlightened, and I'm confident that patients are going to be more likely to receive the quality of care that they really would want.
Brian Lehrer
Professor Frymer-Kensky?
Tikva Frymer-Kensky
I would like to see more discussion of the way to meet death and what to do for patients in terms of both palliative care and emotional support. And perhaps even the development of social rituals for saying good-bye. I am afraid that there will be more worry about economic resources without a general discussion of guidelines, because I think the economic crunch will sooner or later become more visible, and if we don't discuss it generally then we're going to deny help to those who really could benefit.
Brian Lehrer
So 10 years from now we'll be talking more about money?
Tikva Frymer-Kensky
I'm afraid we will.
Brian Lehrer
Julia Quinlan?
Julia Quinlan
I'm afraid I have to agree with you. But I think we have come a long way, and we need to continue to communicate with the patient and with the family. After hearing the discussion from two doctors here today, I'm really impressed, because I'm not quite sure that this occurs in every hospital. In New Jersey or in New York, I think that this may be the exception to the rule. But if we could encourage doctors to sit down with patients and discuss their care, and to talk to the families and say there is no reason to extend the treatment because it is fatal, that would be a big help.
Brian Lehrer
Dr. Prager?
Kenneth Prager
Ten years from now, when the baby boomers are Medicare patients, we're going to be discussing money--no question about it. I think that more states will have legalized physician-assisted suicide, I think there will be a push to legalize euthanasia in the United States, and I think that the technological advances will be increasing the number of ethical dilemmas. You'll be asking questions about things we can't even fantasize about now. I think we'll have a great discussion.
Brian Lehrer
Well, I hope we can convene again in 10 years for another great discussion and see how your predictions have held up. Thank you all.
Stephan Mayer
Hopefully, we'll all make it. Brian Lehrer
Right. I'm Brian Lehrer for Fathom.
