Grandma and grandpa have been in and out of the hospital over the past two years, each time just a little weaker than the last, and now have reached a point where bypass surgery (plus or minus a new valve) is needed if they expect to live out the year. With surgery, they are likely to get a few more years, assuming a stroke, cancer or rampant kidney failure doesn’t get them first. Their doctor has to make a recommendation between choice A, which will probably cost $100,000 to $200,000 (assuming the likely extended ICU and hospital stay and transitional care costs) but will extend life perhaps a few years, or choice B which, with continued conservative care, will likely mean grandma or grandpa with die within 6 to 18 months, maybe sooner. Grandma says to her family, “I don’t know, I’ll leave it up to you,” or, “I don’t want to die.” The family says, “Do everything you can.” The patient survives and is in the hospital for two weeks and then transitional care for a month and goes home. Or, she has fatal complication early (less expensive) or late (more expensive).

I know, I sound cold and cynical. Everyone talks about “cost-effective” medicine as being the panacea for our health-care ills. The brutal truth, which I recognized early in my career in managed care, is that success is expensive and death is cheap. By providing “cost-effective” care, the only way the insurance companies would save money was if the patient didn’t cooperate (or did, depending on your viewpoint) and died suddenly, or moved to another carrier, a variation of musical chairs. Oddly enough, the carriers’ own rules and the legal system, along with our perceptions, increases their cost even in the face of death, as you can see here. Now, the alternative to sudden death, as I’ve intimated, is a slower, more expensive death, and we’ve become more proficient at squeezing every last drop of life out of a person. Even doctors don’t share the same opinion on how to deal with it. Case in point: I once presented the case of a woman in her 80s to a respected intensivist (ICU specialist). She had coronary artery disease and angina, had suffered two strokes with partial disability, and was now dying of pancreatic cancer. Toward the end her kidneys began to fail, one of the gentler ways to exit this life. The family was asked by her doctor if they wanted her to undergo dialysis. Unable to bring themselves to deny this end-of-life care, they consented and the woman died a week later. I expressed the view to the intensivist that, in this case, the option of dialysis should not have been presented. I argued that in moving away from our old, paternalistic approach to medical care we had overshot, perhaps abdicated our responsibility, and no longer spared the family the burden of having to refuse futile care. The intensivist (who had not been involved in the case) disagreed, opining that the doctor offering dialysis could have recommended against it but had the obligation to give the family the choice.

Yes, end-of-life care for grandma and grandpa is expensive. But what about felons? I’ll explore that issue next.


NEXT: The Patients—Felons, Predators and Murderers


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