When Enough is Enough

Figuring out how to reduce health care spending may be an insurmountable task, but the Obama administration is, thankfully, going to give it a try. I hope one of the things that will be under discussion is our attitude about quality versus quantity of life.

One high-cost item for both public and private spending is the care given to sustain the last days and months of life. A disproportionate amount of the Medicare resources are consumed by medical care given to patients who, despite the extraordinary measures, are going to die. There is a growing awareness among nurses, physicians and families about hospice and its services, but still, many families and doctors choose to initiate or carry on with expensive diagnostics and treatments for terminally ill patients.

Even nurses, who fully understand their loved ones’ conditions, are often reluctant to turn from treatment to palliative care. When it comes to family, they often second-guess themselves, always wondering if enough has been done.

This is the sad story I saw unfolding this past week when a good friend who is a nurse called to talk about his 86-year-old mother. She has been in the hospital for weeks after extensive abdominal surgery that was followed by major complications. She also has mid-stage dementia. The surgeon wanted to take the woman back to the OR, but my friend opined that he wasn’t sure a 46-year-old could survive such a surgery, much less an 86-year-old. He was quite conflicted about giving permission.

Then another physician—a British doctor—spoke to him about his dilemma. She kindly but directly told him that if his mother was in England, no one would be considering further surgery. She then explained how doctors could make his mother comfortable with medication and that she should be placed in a skilled nursing facility.

My friend was relieved. He had mistakenly thought the choices for his mother were surgery or painful death. He was comforted in knowing that his reluctance to put his mother through another major surgery was validated. Still, the hospital insisted on calling in the ethics committee to discuss the case because the mother had never signed a DNR order.

All the while, his mother was being denied palliative care and the meter was running.

I thought for sure there would be no follow-up surgery, but an e-mail today from my friend told me that the doctors decided a second surgery was within the palliative realm. Now his mother is in ICU suffering further complications. My friend finally requested that her code status be changed to “comfort measures only.”

“Both of the RNs and the intern (in the ICU) sounded so relieved when I requested, ‘pleasejust consider comfort and dignity, and let her go peacefully,’” he wrote in an e-mail.

And so, a lot of emotional capital, heartache and money have been spent on a situation that never should have occurred. Sadly, such scenarios are repeated daily all over the country.

How do you feel about having to implement extraordinary measures for the terminally ill?

Should physicians be more honest with patients and families when discussing treatment options?

What should nurses say to families who are searching for help in deciding about further treatments?

When considering how our health care dollars should be spent, do we need new national guidance on care for the terminally ill?

Tell us what you think.