Breaking even on the Medicare book of business requires major changes in the way we practiced medicine. So what exactly did I have in mind—rationing of health care? Perhaps, but what I really have in mind is understanding the limits of what we can do. Bear in mind that I write from the perspective of someone who has been taking care of dialysis patients full time for 33 years, but I think a wonderful current example of what I am thinking is contained in an editorial published in the Annals of Internal Medicine 3 August 2010. The editorial was commenting on a paper in that issue reporting the “medium term” results of 126 consecutive patients admitted to ICU’s at Duke University who were survivors of prolonged mechanical ventilation. Medium term was defined as results at one year, when 56% were still alive, but 84% of them were not functionally independent, and 44% of them had marked cognitive impairment. These survivors had also experienced multiple care transitions between the hospital, rehabilitation centers, nursing home, and home. Clearly, survival for the vast majority of these patients was short, difficult, and full of continued debility. Lest you think this problem occurs only in sick patients, the author cited geriatric research showing that patients discharged home from the general medical service of a hospital are still recovering function 18 months later.
In my own field, there has been a recent paper confirming that elderly patients started on dialysis with a decreased level of physical function had further rapid loss of function over the next year. Another paper showed that elderly, debilitated patients residing in a nursing home who were treated with dialysis had marginal increased survival compared to a similar group not offered dialysis, and that the increase in survival just about matched the increased number of days in the hospital. Finally, there was a paper showing that putting patients with stage 5 CKD on dialysis prior to the development of symptoms (early) did not improve survival or reduce complications compared to starting patients with the development of symptoms or at a GFR of 5 ml/min, (late.)
Do these studies mean that ICU care or dialysis is not “worth it?” No, but they do illustrate the limits of what we can do. Said another way, we need to examine our practices over time and from the patient’s perspective. I find, for instance, that if I tell a patient that dialysis is not in their best interest they often accept this with some relief. They already know they are going to die of something—being reassured that they will be cared for and suffering avoided is actually reassuring. On the other hand, a 25 year old patient with no co-morbidity can be expected to do quite well, and I would work hard to reassure that patient that the stress of dialysis and transplant was likely to produce major increase in their longevity and at a decent, although not normal, quality. I really think this is what the Institute of Medicine meant when it was talking about “patient-centeredness.”
Is this rationing? Perhaps, but the goal is to be honest and admit the limitations of our therapeutic efforts. If the patient elects to “give it a try,” I don’t refuse to do it. On the other hand, if the patient cannot give informed consent, I will resist efforts by anxious family members to avoid dealing with the facts when they say “we want everything.” I always hear this as a request to do everything I think will help the patient, not a request to do everything I know how to do. Does it work every time? No. But the patient or family member is always free to seek care from someone else, at least for now, and I am content that I have done my professional duty.
These are difficult questions and issues, and I expect they always will be. I also expect that good physicians will arrive at different conclusions about benefits and risks in individual patients. However, I think the time has come to start dealing with our limits, and re-examine some of our “standard care.”
First, we need to honor the spirit and letter of the patient self-determination laws. These laws spell out ways that patients can make their wishes known. Every time a patient is admitted to the hospital, they are asked about advance directives, etc. Of course, the information is already in the computer from the last hospitalization, but our lawyers are concerned about the risk of error and do not want this information brought forward. This concern is predicated on the assumption that the hospital default policy is to resuscitate everyone. Using language I introduced previously, we have to opt out of resuscitation. Perhaps in obstetrics this is appropriate, but it is not generally helpful on the general medicine wards. I see patients all the time who have “opted out,” but the admitting doctor was too busy to have the conversation so the order was not written. I think we need to sit down and admit to ourselves that the results of in-hospital CPR are dismal and consider how we can educate our patients about those facts.
Second, I think we need to re-consider some of our routine practice. Why do we get daily lab and radiographs in every patient, regardless of diagnosis or prognosis? (Don’t tell me the lawyers make you do it. I am convinced it is an unexamined habit.) Does it hurt? Phlebotomy does, and the amount of radiation exposure can be horrendous, and who knows if it hurts or not. Why do you consult specialists when the problem is routine, unrelated to the issues that determine clinical outcomes, or when you don’t think the patient could survive the procedure? I could go on, but I think you get the idea.
I think we could improve the quality of care and patient satisfaction if we came together and reached a common understanding on these issues. Of course, we will also have to educate our public—something we can probably do corporately as well as individually, but we have access to expert in this task. What is the downside? Perhaps a little less business now, but perhaps better business in the future, particularly with expansion of access to government funded healthcare. What do you think?
Written 17 October 2010, revised 3 May 2014.
 Iwashyna, Theodore J. Survivorship Will be the Defining Challenge of Critical Care in the 21st Century. Ann Intern Med 2010;153:204-205.
 Cooper, Bruce A., et. al., A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis. NEJM 2010;267:609-619.
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