Actual Patient Conversation:
“Man, that Dilaudid didn’t even touch my pain.”
“Uh, Okay. Your CT was negative so you’re fine to go home. I’ll ask your nurse to come discharge you. Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”
“Can you give me a prescription for Vicodins.”
“No. If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing. Stick to the Motrin.
“How about some Demerol.”
“No.”
Another Actual Patient Conversation:
“Vicodin doesn’t even touch my pain.”
“I’m sorry. That’s all I’m going to prescribe.”
“Can you give me a ‘scrip for my Methadone?”
“No.”
“Well, how ’bout a shot of somethin’ before I go?”
“No.”
“Aw, man. Fuck you. I want to speak to the manager.”
“Sir, this is not the International House of Pancakes.”
Darn You, Manny Rivers!
More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today. There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums. The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.
A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.
A day in the ICU costs Medicare approximately $4000 once all the costs are factored in. A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die. ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising. Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.
I blame Manny Rivers and his surviving sepsis campaign. Sepsis is an infection that leads to shock and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound). Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable. The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.
While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time. I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well. We do what the families want, however, rational or not. First because we are conditioned to never give up. Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game. Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.
And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in. It’s either that or have ICU beds sitting idle generating no revenue whatsoever.
But the madness needs to stop. What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare. And it needs to become the standard of care.
Now if we could only find someone to put the bell on that damn cat.
