USA Today this week published another story on the continuing theme of innovative health systems and physician leaders who are finding big cost savings while providing better patient care. I know most if not all physicians are interested in providing more cost-effective care, but a recent encounter in the ER led me to wonder whether patients are ready for the same thing.
I recently took care of an 83-year-old women who came into the ER with interstitial lung disease, a chronic condition that does not have therapy and gets progressively worse over time. The woman had been admitted several times over the previous month to different hospitals for shortness of breath. At one point she was transferred to a rehab facility and eventually to her home. When she came into the ER this time, she was again short of breath. She had her son with her at the bedside.
In my conversations with her and her son I asked if they had had a conversation about end of life care or a living will. The son said that she was not willing to have those conversations. I explained to the woman as best I could that while there were medical things we could do, it would not change the eventual outcome of what was going on inside her body – namely that her lungs were failing. I spoke to her primary care physician and asked whether they had had a conversation about advance directives for end of life care. The physician, like the woman’s son, told me the woman was unwilling to talk about it.
There is no doubt these are tough conversations to have. But physicians must have them, however difficult. The reality is that our medical system provides incredible care to patients in need, but that care comes at great cost. At some point all of us will die. No one has figured out how to live forever. So we are left with a problem: at what point do we as patients, physicians, and as a society say, “enough is enough.”
This is not a discussion about quality of life and value and worth; it is a discussion about reality. The rhetoric in the health care debate can often make us lose sight of the fact that we all have chronic conditions, and at some point we all die. For some of us that will happen years in the future. For others, it will happen in months or days. At some point there needs to be a realization that life is about making most of the time we have, not seeing how many medical procedures can be done to extend what may be a few days into a few more days or a few weeks into a few more weeks.
We need to shift the discussion from one about how much can be done to one about what is the most appropriate thing to be done for me and my life. Palliative care offers the hope of understanding whatever disease you have and how it will impact your life over a long period of time until there’s nothing left medically to be done.
These are hard conversations to have but they are conversations that we as a society and as medical practitioners and patients must undertake. The next time you, a loved one or an elderly family member are in the hospital in a similar situation to the woman I treated, ask yourself: Is this going to change what will happen to my family or to me? How do I want to live my life?
Do I want to spend my last days in the hospital hooked up to an IV? Do I want to spend it at home with my family with support so that the transition to whatever comes next is made as easy and as compassionate as possible? It is your choice and a choice we all must make to save our system of care.