Tuesday, May 4, 2021

End-of-Life Care: A Physician's Tale

Environmental & Science Education
Edward Hessler

You would think that a physician who is an oncologist, a bioethicist, and vice provost of a major university might have some clout when it comes to end-of-life care for a father.

Not so fast. When Dr. Ezekiel Emanuel's 92-year-old father fell ill, "once (he) was admitted to a hospital, it took all my expertise and experience to arrange the kind of care he needed--and prevent the medical system from taking over and prescribing unnecessary interventions." (my emphasis)

Emmanuel's father was admitted to a hospital and before Emmanuel arrived (required a flight), he'd had "a CT scan...an MRI (revealing a brain tumor), and a chest x-ray (suspected pneumonia). The latter led to his hospitalization although Emmanuel writes that "it lacked the local infiltrates that usually signify that condition."

Emmanuel's father greeted his son with the words that are immortally lovely: "'How are you doing, schmucko?'"

The list of things that the hospital wouldn't do and these are detailed in Emmanuel's essay. They did the easy things. Please read these details. And then there is this:

"No one had taken the time to ask (his father) about his wishes regading medical treatment, even though he was competent to make decisions and was himself a physician. No one asked my mother and brother, who were with him in the emergency room and at the hospital, if had an advance-care directive or wanted to have a do-not resusitate order.

Emanuel convinced the hospital and medical staff that they were serious about no, by disconnecting interventions and asked that he be discharged. 

Emanuel's father spent the last days of his life at home where he wanted to be "and was able to say goodbye to everyone.". Turns out it was cheaper, too. The "12 hours in the hospital came to $19,276.83 (so far). In contrast, the more than 200 hours of home care he got over the next 10 days cost only $6,093.

Emanuel calls attention to "why end-of-life care costs are so high, and why physicians cannot seem to reduce them. ...It has less to do with physicians' and hospitals' financial incentives to admit more patients and perform more medical interventions, and more to do with the effort required to order and provide human care." 

I've been around enough undergraduate pre-meds who want to practice medicine to know that they want to help...reduce and tend to human suffering. However, I am less sure that they want to do the near clerical kinds of things that are also often required--calling, making arrangements, getting out of their comfort zones to learn who can provide help with what patients really need at the end of life, and speaking with family members and patients who do not have their training or background.

Emanuel closes by writing, "A terminal diagnosis is inherently traumatic for patients and their families. My father's experience at home before his death needs to become the standard of care. And not just for patients with pushy sons who have medical training and know how to speak with physicians, disconnect cardiac monitors, and firmly refuse the interventions that our health-care systems is so predisposed to offer." (My emphasis).

Emanuel wrote his essay for The Atlantic and may be read there.

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