Early goal-directed therapy raises the age-old question about end-of-life treatment in the ED. How much is too much?
Given that this issue of EPM is dedicated to sepsis, I’d like to address a question that was recently posed to me. Here’s the quandary: If EPs act early and aggressively they can make a difference in the outcome of sepsis patients. But many of these patients are elderly and sepsis may be their last chance to die of natural causes – pneumonia used to be called the “friend of the elderly”. Now we can intervene even more, pumping even more money into end-of-life care. When do I draw the line and say, “Yes, I could fix that problem, but the country can’t afford it”? Where is the balance between patient health and the health of the nation? Do we as physicians have a responsibility to maintain both?
First we must understand that the new treatments for sepsis are the old treatments for sepsis. Having recently reviewed most of this literature, the only two things that are really proven to work are relatively early antibiotics and adequate amounts of fluid. Most everything else is a hoax. All of the studies with steroids, new protein molecules and various central monitoring techniques are basically hype, smoke and mirrors to the nth degree. Give ‘em fluids and give ‘em antibiotics and hope for the best. But this is not the basis of the question being asked. At its heart, the question has nothing to do with the treatment of sepsis. It has to do with the maintaining of life beyond meaning.
There is no country with a national health program that does not have to ask serious questions about economics. As an economist, I believe that every activity in the world – from saving patients to eating dinner – has a price. At some point, we must recognize that what we are doing with many of our patients is prolonging death and not maintaining life. The comments occasionally made that it would be “playing god” to let certain people die are ridiculous. I would remind these docs that every time you practice medicine you are interfering with evolution, natural selection and survival of the fittest. At some point in time, we cannot afford to do everything for everybody.
Real leadership on this question is lacking. There will be no national health insurance program in the United States without financial limitations – name one country without them. The vast majority of European countries and the Canadians function under global budget restraints. Difficult decisions do have to be made. Any fool can advocate spending everything on everybody. It’s going to take someone with intelligence and true leadership to help make the difficult decisions as to what we will and will not accept. There is no health care program for everyone until there is a clear picture of where the limitations will be.
During the Clinton administration, the Clinton health plan died because it could not define what was NOT in the plan. People need to know what will and will not be done. Is maintaining grandma on a ventilator with no perceivable brain function an intelligent use of tax dollars? Why in the world would we maintain rotting flesh when those funds could be spent educating children, helping them become productive members of society? People who cannot understand the nuances of these difficulties have no business running for president of the United States.
On a practical level, emergency physicians need to give the issue of end-of-life care some serious thought, apart from the day-to-day immediacy of practice. The tyranny of the immediate will always force your hand. EPs need to think these questions through in a careful way and decide in advance what they will and will not do. Every day I talk with families about what they expect, what they think will happen and what they want done. And then I try to give them a realistic view of what is going to happen.
The end of life is death. It is a natural cycle. There is nothing that is born that does not die. So the question is: What are you owed by the society at large? A last-ditch-effort gastrostomy feeding tube? $5000-a-day ventilation for a respiratory patient? It’s not like we don’t have other uses for the money. Have you been to Detroit lately?
Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and has directed an ED for 21 years.