An associate of mine admitted a patient, sadly only in his forties, with a very weak heart who nearly died from heart failure after running out of his water pills over a week earlier.  He had a known cardiomyopathy (the medical term for a damaged heart) brought on by a prior history of drug use and by ongoing alcohol abuse. It turned out he also had coronary disease with a severely blocked artery that was contributing to his decompensation. With somewhat heroic measures that included coronary angioplasty, placement of an intra-aortic balloon pump (a temporary device used when there is some chance the patient might improve with a little extra time) and powerful drug to support blood pressure, he managed, for the moment, to thwart the grim reaper. He confided to the nurse that stopping drinking “would be hard.” This is usually an indication he won’t. Surprisingly, this particular patient was insured (most of the patients in this demographic are not) and one of the providers, if the data was correct, was Medicare. I’m uncertain what diagnosis qualified him for Medicare at his age. In any case, this example points to an issue that people find difficult to address: What is futile care?

This particular patient has two terminal illnesses: his alcohol abuse and a worn out pump. He will be lucky to live out the year, especially if he continues to drink. The only thing in his favor for a dash more longevity is the fact that the event was triggered by noncompliance with his medications. Unfortunately, he’s now on antiplatelet medications that will make him more likely to bleed if he continues drinking, and he’s not likely to survive anything more than the mildest of hemorrhage. If he drinks and stops his medications, he runs the risk of clotting off the stent in his artery or going back into decompensated heart failure, both life-threatening turns he’s not likely to survive.

The expenses he’s incurred just from this visit (and I imagine he’s had many more related to his diagnosis in the past) and what he’s likely to incur prior to his death (barring a sudden outpatient demise which is equally likely) are in the tens to hundreds of thousands of dollars. Given the shortage of resources and the many productive, indigent patients that do without, can we continue to justify such outlays to extend a life for a few more months while the patient continues to destroy himself? Is this the measure of a compassionate society?

This brings me to the larger question of societal values in general. Having flogged the issues of the health care industry for greater than a year, I’m going to broaden the arena of my rants in subsequent posts, returning to the health care crisis as events dictate. Many of us believe we’re at a crossroads at this time that will determine not if the health care industry can survive, but our way of life.

I think that the jury, and the doctor, is still out.


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