NEW YORK, NY / The New York Times / Opinion / December 12, 2011
When Care Is Worth It, Even if End Is Death
By Peter B. Bach, M.D.
I met him in the emergency room of the hospital, just a year after I finished medical school.
His cardiac monitor, the first thing I noticed, showed fast and irregular beats with bursts of a messy, wavy rhythm called ventricular tachycardia. His heart was convulsing.
Then I looked at him: a middle-aged man breathing rapidly and lying very still, complaining of belly pain. My first thought was that the blood flowing to his large intestine had clotted off. That explained the symptoms. Soon, if not already, bacteria would start to leak into his bloodstream from his gut. Then he’d become overwhelmingly infected.
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My supervisor summed it up a few minutes later, mumbling to me that my patient was in the last hours of his life.
I called the surgeons and took the patient with me to the intensive care unit. Three weeks later, he walked out to the hospital parking lot, accompanied by his family. We had saved his life.
No one would call what happened over those weeks a waste of health care dollars. But if we change the ending of his story, if my patient had died despite our efforts, many policy analysts would have called it just that.
You’ve probably heard that we spend a lot of money on patients who die. It’s true: about one-tenth of the money spent on direct care goes to people who die each year. Among Medicare patients, the figure is much higher, about one-quarter.
You may be shocked by those statistics. What health care system would squander so many dollars on patients who don’t benefit? Or maybe you’re saddened. No humane system would subject patients to painful interventions and procedures that serve no purpose.
The idea that we waste money on terminal patients has caught on; the simplicity of the conceit makes it appealing to policy makers. And the data to support it keep coming, because it is easy for researchers to measure how much is spent on patients before they die.
For instance, researchers at Dartmouth College publish rankings of hospitals and states based not on how successful they are at preventing deaths of patients who are very ill, but on how much they spend on those they fail to save.
The same is true of some of the latest doctor quality measures promoted by national organizations, including some for cancer doctors. These examine how often these doctors’ patients were given medications that could prolong their lives or alleviate their suffering before they died. In the metric-maker’s eyes, treating such patients before they die is bad, not good.
But what about my patient? How could it be that we were prudent with health care dollars because he lived, but would have been described as wasteful had he died? Doctors in an emergency room cannot know which will occur. They do not have divining rods that direct them to patients they can save and away from those they can’t.
Rather, caring for the sick means caring for people who may die. Providing care means reducing the chance they may die — not eliminating it. My supervisor noted this the moment he saw my patient.
National statistics confirm this. Seven of eight people with my patient’s diagnosis, called mesenteric vascular ischemia, leave the hospital alive. That means one in eight, or 13 percent, die. That is tragic. But the decision to care for all eight of these patients cannot be judged by the one failure alone.
Put another way, the policy conceit that spending money on patients who die is a waste overlooks the core purpose of health care — to prevent or forestall illness, disability and death among patients at risk of those outcomes.
It also overlooks a key correlation in health care. When people get sicker, they need more intensive — and expensive — health care services. But when they get sicker, they are also more likely to die. When I met my patient, I took him to the intensive care unit, the second-most-expensive place per minute in any hospital. The other place he went, twice, was the operating room — the most expensive place.
Healthy people, who are unlikely to die, are also very unlikely to find themselves in those settings. Thank goodness.
Thus, spending will always be concentrated on people who are the sickest. When one examines spending on patients who die, dollars will be concentrated there, too.
I am not saying that every health care dollar is well spent. But five carefully done studies have now shown that hospitals that spend more on caring for sick patients have better outcomes than those that spend less. So some of the spending is improving health.
Neither am I saying my patient’s experience is typical of what happens in health care. There are also stories of patients who suffered needlessly, enduring treatments and procedures that could not possibly help them. Wasted dollars, harmful management.
The more nuanced reality is that some aggressive treatment delivers value and is appropriate, even though some patients who receive such care die; other treatment is too aggressive and should be curtailed no matter what the short-term outcome. No one knows how many patients are more like my patient, who could have died but whose life was saved, and how many undergo treatments and tests even though there is no meaningful chance they will benefit from them. The important thing is that it’s not all of one and it’s not all of the other.
Today the medical profession lacks a shared understanding of which patients are which. That gap must be addressed. It will be an excruciating task, and it will be politically noxious. Someone will again accuse officials of forming death panels. But leaving the distinctions to individual doctors leads to inequities, harm to patients, distrust in medical care and lawsuits; ignoring the problem should not be an option, either.
One might even hope for a discussion over which jaw-droppingly expensive treatments with small benefits are worth it when given to patients with a poor prognosis, and which are not. There are many new treatments that fall into this category including some cancer treatments. But we are a world away from having such a discussion at a societal level.
For now, the most important step is to question the notion that all spending on patients who died was futile because the outcome was a bad one. That idea stands in the way of a more rational discussion over what best serves patients who are ill.
Dr. Peter B. Bach, a senior adviser at the Centers for Medicare and Medicaid Services from 2005-6, is the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center in New York.
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