by Del Meyer

Part of my responsibilities at University of California, Davis Medical School, include teaching physical diagnosis. This means teaching and observing second-year medical students as they obtain a medical history and perform a physical examination. Sometimes I observe and instruct them in my office and other times in the hospital. Recently I had a patient in the cardiac unit who was a willing volunteer in this learning process.

While recording the students’ skills, I was able to observe the patient in the next bed who had a coronary artery bypass. She was lying still in her bed, looking at the ceiling, surrounded by her family talking amongst themselves as if she weren’t there. When the student physicians had completed their examination of my patient, we stopped at the nursing station to talk with the nurse who was taking care of the patient in the adjacent bed.

The nurse told us that the patient had Alzheimer’s Disease and had not recognized her husband or children in several years. The nurses had a hard time understanding why the heart was being rejuvenated to last years longer, when the brain had ceased its cognitive function. Most of us feel that when the brain goes, hopefully another organ will fail so that the body can die along with the brain that has essentially “died.”

This reminded me of a conversation I had with a member of my parish. He stated that his mother, who was 91 years old and had lived alone a few blocks from them, had some mild chest pain. Her personal physician was treating it with the usual nitrates. He referred her to a cardiologist “since there are a lot of new medications on the market and perhaps she could benefit from one of them.”

The cardiologist immediately did a cardiac catheterization and found some vessels that were nearly blocked. He had a cardiac surgeon see the patient and he immediately scheduled her for a coronary artery bypass graft (CABG). The operation took place the following morning and was accomplished by taking some veins from her legs and grafting them to either side of the coronary artery blockage. After five days, the family was told that she, being old, was unable to be discharged home, and should go to a nursing facility for a month or so. She spent over three years and died there.

My friend said that his mother’s chest pain had not been all that severe or disabling and did not interfere with her usual minimal activity. But after she was referred to the cardiologist, the family lost control. In hindsight they felt it would have been preferable if she had remained in her own house near them, even if it meant that she might have lived for only six months to a year before her coronary caught up with her. It had been difficult to visit her in a convalescent home for over three years. The cost of $3,000 per month for 40 months was covered by selling her house. And of course, Medicare paid for the $120,000 hospital bill with taxpayer revenue. The surgeon’s fee of $6000 was almost inconsequential in relation to the quarter million that was spent on the last three years of a life which was devoid of quality. The family felt that there would have been greater quality of life without that quarter million-dollar expense.

A variation of that scenario was being replayed in the next bed my student physicians were observing. The critical item that would control such unnecessary costs is usually missed. Neither the patient nor the family had any financial consequences from that decision and may not have had the fortitude to go against the tide of surgical opinion. However, if there were a 5% or 10% copay that the hospital would have told the family to pay, they immediately would have had a family council or discussion on “Do we really want this for our wife and mother?” We see that in healthcare cost projections; it is generally considered that healthcare needs are fixed. As these two examples show, it is very elastic. From my own personal, clinical, nonscientific observations, there is at least an excessive 30% utilization that could be avoided with the appropriate incentives.

While elements of our society are debating end-of-life decisions, physician-assisted suicide and euthanasia, the impetus for this direction is heightened because we don’t allow people to die when the next stage in their illness is to die with some dignity. But the push for this allowance has to come not only from primary care physicians, but also from patients and their families who must remain involved in every decision that concerns their loved ones. Otherwise, in our illness or in our desperation, we may not recognize whether our doctors are adding to future misery by prolonging dying, or really giving us improved or even acceptable quality of life.