In the June 2008 issue of Emergency Physician Monthly, Dr. Henry writes a column entitled “Should Sepsis be the Friend of the Elderly?” This piece presents a disturbing and controversial perspective of aging, health economics, and ethics…
End-of-life spending is a critical issue in the United States. Americans spend twice as much on medical care per capita as the second highest spending nation with poorer outcomes than less costly systems. The use of an individual’s age as a stand-alone criterion to decrease the cost of care is a slippery slope all too appealing to bean counters. Nowhere in Dr. Henry’s piece is there discussion of the differences between biological and chronological age. In the examples given, an 80 year old golfer (or marathoner) would be treated the same an 80 year old debilitated, severely cognitively impaired nursing home patient with a DNR order. As expenses exceed resources, interventions should be provided to those most likely to benefit. Evaluation of age alone is insufficient to make decisions of this nature. Who decides the definition of “old” or “debilitated”? Will double-standards guided by social hierarch apply? Who will be the judge of “appropriate care” or fiscally responsible health care spending?
The opinions expressed in the column open the discussion of sepsis treatment to critical moral questions. To whom do we deny care? Who makes the decision? What criteria are applied? How do we reconcile our actions with the foundations of medical ethics such as patient autonomy, beneficence, and justice? How does letting a patient die of sepsis fit with any of the above? Please consider the AMA document on physician ethics from 2001 that states: “A physician shall support access to medical care for all people.” Access and delivery of care to all in need is the sacred trust of the emergency physician. Do we now exclude elders?
There is no evidence that denial of antibiotics to treat older adults with sepsis would result in a significant reduction of health care costs in the United States. If we as a society decide that health care costs need to be reduced, there are many strategies that first can be employed that do not restrict health care outcomes. If rationing is required, it should be based on sound ethical principles. Rationing as a society would require consensus guidelines based on medical evidence and acceptance by physicians, ethicists and policymakers regarding specific treatments that should or should not be provided. It is crucial that any decision to withhold care not be determined at the bedside by an individual physician; it is well known that bedside decisions, not based on consensus standards, are subject to prejudices such as ageism.
Emergency clinicians will increasingly be faced with the “quandary” of caring for older adults as the US and world population ages and the demographic shift increases the proportion of older adults using the health care system and our emergency departments. It would behoove us and the health care community to think carefully about how we as individuals view our patient population and how we will care for them as they age.
Edward S. Bessman, MD
Christopher R. Carpenter, MD, MSc, FACEP, FAAEM
Joel Gernsheimer, MD, FACEP
Lowell W. Gerson, PhD
Teresita Hogan, MD, FACEP
Frederic M. Hustey, MD
Ula Hwang, MD, MPH
Jacques S. Lee MD, MSc, FRCPC
Eve D. Losman, MD
Luna Ragsdale, MD
Barbara Richardson, MD
Arthur B. Sanders, MD, MHA, FACEP
Manish N. Shah, MD, MPH
Michael Touger, MD
Scott Wilber, MD, MPH
Steven J. Davidson, MD, MBA
Continue Next for more letters in response to Dr. Henry
I enjoyed Dr. Greg Henry’s recent article on sepsis. Dr. Henry is an incisive thinker, and of great importance to our specialty. I believe he makes an excellent point; we frequently find ourselves struggling to fend off death in situations that are, for all intents and purposes, hopeless. And such battles are financially costly. Our medical system spends vast amounts of money at the end of life. There’s always somewhere else we can use that money.
But I think we need to use great caution here. Our medical system is in a mess for some very good reasons, chief of which is that our cultural heritage, our spiritual heritage, is one that recognizes the intrinsic value of every human life. We even value old lives, whose attempted rescues are costly. It is the ‘price,’ as it were, of valuing all life.
I think it’s reasonable to worry about playing God. Because if we succumb and say ‘well, we must let evolution, natural selection and survival of the fittest have their way,’ then we will cease to play God and begin to play Darwin. And in the extreme interpretation of that view, there is ultimately no meaning other than physical survival. In that scheme, ultimate meaning is reduced to useful existence; useful to the species, perhaps to the tribe or family; possibly the nation. But once utility is transcended, there is no further reason for that individual to continue using resources that might advance the species or group. If we adopt such a view, one might reasonably call into question the very purpose of medicine as a science and a profession. For nature will decide all, from the diseased newborn to the injured worker, the cancer-ridden mother of three to the HIV infected homeless.
We would certainly spend less, wouldn’t we? But how many of us would be alive today?
Edwin Leap, MD
The end of life issues you raised last month are so very true. Everyone wants everything all the time, but no one wants to pay for it, no matter what the costs are. Keeping an essentially lifeless body indefinitely on life support makes absolutely no sense. I always say to my patients’ families: the quality of life is what’s important, not the quantity”. Just existing doesn’t cut it. It’s no different that nursing home patients with severe dementia with foley catheters who we aggressively treat with high power antibiotics every time they get a UTI or even pyelo, thinking we’re “saving” them. At some point something is going to kill all of us, whether an MI, Stroke, Infection, Trauma. It’s got to be something. We as a people need to understand that and accept it. We can’t all “live” or I guess “exist” indefinitely and expect someone else to pick up the tab. I would love to see how some of these families who say “do everything” to grandma with dementia would react when they actually would be responsible for a bill of over $100K. I bet they would be more prone to ask more questions and weigh their options. I am not saying we have to be inhumane. People take these things to exaggeration… My 87 y.o. father takes no meds and goes shopping by walking everywhere, everyday. Would I get aggressive with him with an infection? Absolutely. But I also have taken care of a five year old who unfortunately sustained hypoxic brain injury at the age of two, who now is living on a vent, has tubes everywhere, who is being indefinitely “sustained” while he has absolutely no quality of life and is not expected to do so anytime soon, at the cost of millions. I can’t understand that at all, when the millions spent on that one child could be spent on improving preventative services to the poor “healthy” children in our under-served areas.
Shant Garabedian, DO