Operating on the Dead

This past week I was on call for the hospital. Without a doubt, the worst part of my job. I was called to evaluate a seventy something year old male for a tracheostomy. He had a major stroke and was hooked up to a ventilator for a couple of weeks. He had major medical problems and the chances of him surviving this episode was nearly zero. However, his family felt they were doing him a favor by insisting that all measures be taken to keep him alive regardless of the fact that he was suffering needlessly. I felt terribly being asked to put this man through a surgical procedure with its associated postoperative pain. But my hands were tied and I could not go against the wishes of the family. The risk of a complication is great because of his medical condition which places me at risk for potential legal action. For all this stress, time spent in family consultation, time spent performing the surgery, and potential liability for any untoward sequelae I will be paid about 200 dollars. Now you know why I hate taking call at the hospital.

I have written before and I will reiterate that we, as a nation, must have the conversation of end of life care. It is bankrupting us as we spent a fortune in the last two weeks of a person's life. We cannot rely on the patient's family to make the difficult decisions. They are not in a position to rationally decide on their parent's or spouses care. There are too many emotional attachments that distort their decision making. Therefore, it is imperative that every person must have an advanced directive so that their wishes are explicitly laid out prior to their eventual illness. Simply, you will decide if you want heroic efforts taken when the time comes and which will be clearly spelled out. If you have an advanced directive your insurance premiums, ie medicare payments, would be reduced. If you fail to have an advance directive or you want heroic measures to be taken you will pay additional premiums during your lifetime. This makes complete sense.

I was reading an article the other day that was very interesting. It is somewhat counterintuitive but makes sense if you think about it. End of life care is significantly more expensive for a 70 old than a 100 year old. The reason is that the 100 year old is likely to die from a sudden event without time to receive medical care and the family is less likely to pursue heroic measures at that age. Additionally their 70 or 80 year old child who is making their medical decisions understands the need for compassionate end of life care better than a 30 year old would. On the other hand, the seventy year old is more likely to have a chronic illness and will sustain a more drawn out end of life process requiring multiple hospital admissions and large costs. This demonstrates that maintaining a healthy lifestyle not only decreases the burden you place on the health system at a younger age but also the costs you incur at death.

A large majority of chronic illness is the result of lifestyle choices. Overeating and obesity, sedentary lifestyle and lack of exercise, cigarette smoking and avoiding preventive care all incur tremendous burdens on our health care system. Right up to the last seconds of life the bad choices that people make drain our resources and stick the rest of us with the bill. It is critical this be addressed and remedied. These are difficult decisions and conversations that require leadership by our elected officials. As I wrote last week about adaptive challenges, there is no imposable solution. Our leaders must challenge us to change our thinking about end of life care. To take responsibility for our own health and to have an advanced directive to dictate what we each would want done when we all reach that final stage of life.