The new IT article on health care: How American Health Care Killed My Father, by David Goldhill, writing in the September 2009 Atlantic.
Richard Dooling on NPR’s Talk of the Nation discussing his opinion piece in the New York Times, “Heath Care’s Generation Gap.”
It was my first novel, and I wrote it almost two decades ago, but I doubt I’d change a word of it. If anything, the money and the madness changing hands in the ICU have only gotten worse. When I wrote Critical Care, circa 1990, total expenditures for health care ran at roughly 10% of our gross national product. Now, as my opinion piece in the New York Times indicates, it’s 16% and headed for 31% in the next 25 years, unless something changes.
The new hysterical fear is that if we counsel elderly patients about end-of-life choices it means we are “pulling the plug” or sending them off to suicide parlors. People need to know what all of this aggressive, no-holds-barred, spare-no-expense intensive care buys you at the end of life. It’s not pretty, and that is the real subject of Critical Care: What happens when modern medicine doesn’t know when to quit.
Here then, by popular demand, is an excerpt from an early chapter of Critical Care: A Novel:
Resignation was the order of the day. Everybody from the nurses on down to the respiratory therapists and the lab techs had already privately agreed that Bed One would ‘code’ sometime tonight, code being short for Code Blue. Bed One’s heart would stop beating, or he would stop breathing, or both; the hospital operator would then announce: “Code Blue, Ninth Floor Intensive Care Unit” three times over the hospital’s public address system, and a dozen or so specially trained personnel would then descend on Bed One, snap Bed One’s head back, pump Bed One’s lungs full of oxygen with an ambu bag, inject massive doses of expensive drugs in some of Bed One’s veins, draw blood for expensive tests from other veins, shock Bed One with electricity, beat on Bed One’s chest, and generally do everything possible to jump-start Bed One, as if Bed One were a ’57 Chevy that should have been taken to the junkyard twenty years ago, and the doctors and nurses were a bunch of drunk teenagers whose car had broken down on the way to a pig roast.
It would go on for hours. It would require more blood, stool, and sputum specimens to be drawn and sent to the lab. Worse yet, everything would have to be scrupulously documented for the Legal Department. Afterwards, there would be witness interviews, probably depositions, just like the ones they had after the craniotomy in Bed Seven was struck by lightning that came in through the TV set.
Bed One had no business dying from a simple valve replacement. The lawyers knew that.
Because it was 3:30 A.M., Werner was solely responsible for the likes of Bed One. All the real doctors and primary physicians had gone home, had barbecued steaks, had watched a few hours of cable TV and had gone to bed. In Werner’s capacity as House Officer, Werner had to respond to every medical emergency occurring outside the normal hours of the medical work day: like Bed One dying too soon.
“This is what makes it all worthwhile,” he said to a wombat at his elbow. “Being able to help people. This is where training pays off.”
Werner looked the impending medical crisis squarely in the eye and measured himself against it, his self-confidence barely surmounting sleepless anxiety. As usual, he fought the urge to panic by silently reminding himself of his credentials: I am Doctor Peter Werner Ernst. I graduated at the top of my medical school class. I was Editor-In-Chief of the University’s Journal of Medicine. I am qualified and capable of practicing medicine. I will not panic or succumb to stress and make the wrong decision. That would be irrational and inconsistent with my past performance.
Given the hopelessness of Bed One’s situation, another medical resident might have thrown up his hands and accepted the inevitable descent of the patient. Another resident might have been discouraged by the resignation on the faces of the Intensive Care Unit nurses–faces that said ‘Bed One is about to code, creating boatloads of pointless labor and paperwork for us all.’ Yes, another resident might have allowed the normal course of human events to degenerate into chaos, death, and a Code Blue. But not Werner Ernst. Werner was blessed with a superior medical mind, trained in the healing arts.
Werner’s rigorous training had prepared him for this moment, when he, the House Officer in charge of the Medical Center and the resident physician immediately responsible for the welfare of Bed One, would come up with the right combination of medications to drip into Bed One, just the right mix of dosages given at just the right intervals, to keep blood pressure up, keep CO2 down, keep heart beats passably even, and urine flowing . . . keep everything just so, for six or seven hours at least . . . so that Bed One would go down the tubes and croak on the Day Shift, not the Night Shift. So that Werner could eat and possibly nap tonight, instead of presiding over the death of a corpse. So that the ICU nursing staff could embroider or read romance novels through the wee hours. So that Bed One could sleep one, last, peaceful, vegetable sleep before being assaulted by a Code Blue wrecking crew trying to save his life. And, above all, so that all the wicked, ridiculous insanity concerning the demise of Bed One (who, only two months ago was a grandpa, a loving husband, and dad to the people who had brought him here) would come down on Bed One’s primary physician and the Day shift. The Day Shift had advised Bed One and Bed One’s family that eighty was not too old to try for another valve replacement. Eighty? Bed One’s primary physician, Bed One’s chest surgeon, and Bed One’s family made Bed One’s bed of slaughter and anguish, why should Werner and the Night Shift sleep in it?
Excerpted from Critical Care: A Novel, by Richard Dooling
If you’d like, you can read all of chapter one at Amazon.
{ 12 comments… read them below or add one }
In my opinion ‘Critical Care’ should be required reading.
Having thrice been on the receiving end of medical imcompetence I can state that, from my experience, our medical establishment is a scam concocted by doctors and lawyers to extract as much money as possible. The Hippocratic Oath is a sham, since few, if any doctors volunteer to make amends when they screw up.
Why would you ever want to be hooked up to a machine at the end of life while the system performs a fundectomy on your net worth? Better that money go to your heirs to pay for things like houses and college tuition for grandchildren, so man up and go out with some dignity. Nobody here gets out alive anyway.
Mr. Dooling, I came to check out your web site after seeing your column on the generation gap reprinted in the Dallas Morning News.
I agree with what you say in your very well-expressed column about the costs of “heroic measures” often outweighing the benefits. The salient phrase for me, was your description of the attitude: “getting old and dying is a medical emergency.” From my perspective, this is a part of an overall attitude that wants to deny any limits on human beings, including the ultimate insult, our mortality. We shall be as gods, and we shall do it through Science. This rebellion against all that is greater than ourselves leads directly to suffering.
Having said that, I had to ask myself why families continue to bankrupt themselves for treatements they know will probably not work, and that are clearly causing suffering to the patient. Besides the naive trust in the medical establishment that our idolatry of Science creates, I think there is another, more profound reason. We are up against some very basic human drives. One is to avoid death at all costs. Another is to honor our elders and do everything we can for them, even when what we can do becomes largely symbolic rather than effective. I think this is a universal human behavior that will never be eradicated – and, frankly, it’s not all bad. People in every society will do everything they can to demonstrate love and honor to their parents and grandparents. In some places, that just means spending a lot on funeral rites (think
Asia). It’s our misfortune that technology and industry have placed (barely) within our grasp things to do for our elders that come at a horrendous cost to them and us. However, I don’t think you’re going to get most people to stop taking all those measures as long as those measure are available. It’s just not human nature.
Good point, Jen.
One way to avoid a debacle at the end of life is to do our best to make these decisions BEFORE we end up in the ICU. We tried that, and it was promptly shouted down as a death panel. If family members and elderly patients could see what it’s like to die in intensive care units, fewer people would go there, less money would change hands, and people would spend the end of their lives the way most of them imagine it: At home, in bed, surrounded by friends and loved ones.
Richard:
Here is an idea for you. How about if the Government pays for everything that my family and I want or need and nothing that anyone else wants or needs.
Tongue in cheek? Of course.
Ultimately, the problem of overspending on the aged will be improved, but it will be done quietly, out of sight of the masses. Some folks think that everything should be done in a public forum, but it almost never works that way. Call it human nature.
Government has the Midas Touch in reverse. Yes our health care has many problems. I however want it to remain as it is. Individuals via the private sector will change it by our own actions. Robert has it spot on.
There really isn’t much to say. “Dr”. Dooling , you are a monster!!!
Just eavesdropping on some of these discussions. Scary. It’s pretty stunning how defensive and even paranoid people get when you start talking about any kind of regulation of health care.
Unfortunately, people who believe that healthcare regulation means forced euthanasia for everyone over 85 clearly are not listening to much of anything other than their own fears and distortions, and it’s not clear that one can have any kind of real discussion with someone operating from this basis who needs to polarize the discussion in this fashion, or who needs to turn reform of what is a crazy system into cruel acts by evil figures trying to “pull the plug on grandma.”
I think if Barack Obama is making any mistake it looks increasingly that he is naive about reaching a consensus with people who are operating from this basis, or from any base of rigid ideology and who simply don’t want to listen to what the human experience is like for the average patient in our health care system. Unfortunately, and rabid free-market ideologies to the contrary, the average experience in this country for patients trying to get healthcare and trying to get basic answers to simple questions about their health is unfortunately far worse again on average than for people in any major European country receiving “government health care.”
Our system is completely broken and it’s broken in many, many ways, some of which I tried to outline in my previous post. At bottom, it’s not really a healthcare system, it’s an end-stage disease care system, and many if not most of these chronic diseases could have been prevented or at least have their onset seriously delayed, if there was any sensible and concerted focus on prevention. Unfortunately, prevention doesn’t pay squat in this country, so we simply don’t do it. On the other hand, high-tech tertiary care of an advanced disease of aging (pick any of them) pays extremely well, so we do tons of that. Unfortunately, that kind of care often times does very little to preserve quality of life (indeed it oftentimes constitutes a virtual assault on the patient), and it essentially represents closing the barn door after the horse has escaped. As Mark Twain once said, “you can’t expect someone to understand something if their salary depends on their not understanding it.”
Some folks are commenting on the NYTimes Op-Ed health care piece on other pages. See, for example:
http://www.richarddooling.com/index.php/about-richarddoolingcom/
and
http://www.richarddooling.com/index.php/7/
I am a nurse. I currently at work at a nice medium sized not-for-profit hospital in the mid-west. I work in infectious diseases, one of the fields that has been extraordinarily successful at saving lives and improving well-being. One other area as I understand it is trauma care. Persons mangled by injury or accident can and do in many cases get mended and, with sufficient luck and therapy, continue on to live productive lives.
However, in my earlier days when I practiced in the emergency room and critical care unit where codes and extraordinary measures were routine, one has to ask the question “at what price life?” We have amazing tools and procedures available to us today. Just like the code in “bed one” above it seems to be a foregone conclusion that using all of them at all times is compassionate.
(That same mentality has transferred over to our pets as well…echo cardiograms, dialysis, chemotherapy. When I was a kid, there were limits to what a family invested in its pet. Nowadays, vets, like doctors are trained to make all these expensive interventions available and we feel obligated to use them. I’m not comparing caring for Snoopy the same as caring for Grandma, but rather to demonstrate the point the saying NO is very difficult. Because doing nothing is difficult as well.)
Over the years I have seen many people use hospice but it is usually not until the very very end. People still equate hospice with giving up, with doing nothing. But doing “nothing” is hardly nothing…hospice is where doing nothing means letting go of all the medical “miracles” and letting the care return to the whole patient – physical as well as emotional comfort.
Considering our options at the end of life, officially known as advance directives, is hardly a reason to become hysterical and condemn people to hell. Investing less in medical miracles during the last 6 months of life will make us better able to provide compassionate care to those who are dying, and better able to provide wellness care to those who aren’t, young and old.
We are all part of the same family and share at least one thing in common – we are all going to die. Continuing to live with the illusion that modern medicine can take that ultimate truth away or make it easier for anyone, the patient, the family or the caregivers is foolish. I’ve seen too many elderly people on machines, with a dozen or more tubes, cut up, disfigured, infected and otherwise brutalized at the end of life. This is torture for them and torture for their families. But until we really answer the question “at what price life?” we will continue to spend ourselves into oblivion and be all the worst off for it.
Looks like Rupert Murdoch, above, could use a bit o’ the old end-of-rope care himself. Perhaps a block of ice, for starters and enders, the better to start chillin’ like Majillan, stat…
Hi Richard – Thought you might find this of interest. Best, DW
Rethinking Our Losing Battle Against the Diseases of Aging:
Why We Are Losing the Battle – What We Can Do Differently
What is aging, and why does it often lead to the diseases of aging? What can we do about this? These are central biological questions for all the healthcare disciplines, and questions around which there is now a great deal of fundamental science. Unfortunately, very little of that fundamental science has trickled down into the healthcare system and into the awareness of most healthcare professionals. And almost none of it seems to inform the way our healthcare system currently works.
Although the Bible refers to aging as “the wages of sin,” this is at best a colorful metaphor, and of course completely scientifically inadequate. Instead, the evidence is that aging is more related to the “wages of metabolism” (oxidative stress) and the “wages of organism defense and repair” (AKA inflammation).
This talk looks at the impending failure of the national healthcare system in the United States (we are headed within the next several years into a situation in which roughly 20% of the national GNP is going to be spent on healthcare expenses) while overall health and quality of life is declining (currently the United States ranks between 30th and 45th in life expectancy). As the baby boomers (almost a 60,000,000 person demographic) hit the decades of greatest risk for cancers, heart disease, stroke, arthritis, Alzheimer’s disease, macular degeneration, and increasing diabetes, the evidence is that the healthcare system (as it is currently structured) would undergo a catastrophic collapse. Obviously, this collapse will not happen all at once, (and instead the evidence is that it will be slowly swamped over time with subsequent progressive and stark rationing of care). If we continue on our current course, we will see an increasing fraction of our national wealth going to healthcare, but with every indication that our quality of life will not be improved correspondingly at all. Currently, we spend at most 5% of our health care dollar on prevention in any meaningful sense, while somewhere between 75 to 85% goes into the treatment of an established disease of aging, often times emphasizing high-tech tertiary care of an advanced disease of aging, including spending roughly $100,000 or more in the last year or so of life. These figures of course are completely unsustainable within the context of the aging of the baby boomer demographic. Given the explosion of obesity in this country (a risk factor for all the diseases of aging and not simply diabetes), the incidence of the diseases of aging may actually be on the rise, suggesting that the American culture as a whole may be headed for a catastrophic failure of prevention in relationship to the diseases of aging on a national and unprecedented scale.
This talk examines evidence that the classic lifestyle factors of diet, exercise, sleep, and stress all impinge on three fundamental mechanisms that drive all the diseases of aging: 1) oxidative stress which damages numerous cellular compartments including the mitochondria and mitochondrial DNA (a potential nexus of aging change, leading to age-related change and apoptosis), nuclear DNA (potentially leading into cancers), and many other membranes and protein structures; 2) chronic auto-inflammation which contributes to oxidative stress (our immune system kills invaders in part by overloading their antioxidant defenses) and which also causes damage to multiple systems and tissues; 3) glycation of proteins, and the creation of increasing amounts of so-called “advanced glycation end products,” which potentiate inflammation. These processes also jointly contribute to the over selection of apoptosis and drive tissues eventually into having increasing populations of senescent cells that are unable to do their assigned physiologic tasks.
Four lifestyle factors are critical. Sleep, exercise, a healthy diet (which is more than just reducing calories and must include critical phytochemicals), and not too much chronic stress (acute stress once resolved appears benign) combined with a healthy emotional outlook directly impact these fundamental cellular processes of age-related damage. All of these lifestyle factors contribute to the reduction of inflammation in aging, the optimal management of oxidative stress, and the minimizing of glycation of proteins. Indeed these four components of a healthy lifestyle probably have synergistic effects, just as a bad diet (too much calories, too few protective phytochemicals, poor Omega 3/Omega 6 ratios) synergizes with the effects of sleep deprivation, sedentary lifestyle, and excessive stress in promoting inflammation, oxidative stress, and glycation. Jointly, these classic lifestyle factors determine what aging trajectories our systems enter as we get older, and how much our fundamental cellular defenses against cellular damage are supported and enhanced as much as possible, versus overtaxed and overwhelmed. Mechanisms of aging lead invariably into the diseases of aging if given enough time and enough room to work. At this point there is no cure for virtually any disease of aging, so prevention, instead of being put in the trunk of the car where it sits currently in our healthcare system, needs to be in the driver’s seat. Making this critical change in priorities and approach is likely to be both painful in many ways as well as politically contentious.
The talk also summarizes work on calorie reduction, which is clearly the gold standard in relationship to both aging and the diseases of aging. Calorie restriction, which functions as a kind of global metabolic reprogramming for virtually all organisms, extends lifespan and reduces penetration of the diseases of aging significantly if not dramatically in every species in which it has been studied. The talk briefly examines what we know about calorie restriction mimetics (substances that mimic the effects of calorie restriction without the “pain” of substantially reduced calories), particularly resveratrol, which is the most popular and best researched calorie restriction mimetic that is relatively available. It also briefly examines effects of other common polyphenols, widely regarded as “antioxidants” such as turmeric and catechins (found in green tea), summarizing evidence for a very multifactorial pattern of effects from polyphenols, far beyond their simplistic designation as “antioxidants.” While the antioxidant vitamins (A., C., and E) are a complete bust in relationship to the diseases of aging, and this has led to enormous skepticism about the value of anything labeled as an “antioxidant,” polyphenols affect cell signaling and cell physiology in a wide variety of ways, in the direction of enhancing antioxidant defenses, modulating excessive inflammation, regulating growth versus apoptosis pathways, and reducing glycation of proteins. As a class, they are looking like the most protective dietary compounds in relationship to aging and the diseases of aging yet discovered, and their effects extend far beyond the reduction of oxidative stress. Large-scale trials are now underway of resveratrol and other polyphenols in relationship to several diseases of aging.
The talk concludes by emphasizing how far Western technological societies have moved from an original evolutionary environment (a great deal of exercise and sleep, low-calorie, high phytochemical diets, within socially intimate groups), and suggests that the diseases of aging come from our living longer (we have conquered infection for the most part) but while living in an environment which is fundamentally alien from the one in which we evolved. Two long-term solutions (to both avoid the long-term financial collapse of the healthcare system and enhance quality of life) might emphasize: 1) finding and using effective calorie restriction mimetics; 2) major lifestyle changes, so that we exercise and sleep more, eat less, eat better, and aim more for quality of social connection than quantity of consumption.
Healthcare professionals of virtually all disciplinary persuasions need to take responsibility for educating both patients and the general public about these issues, as a critical part of the reprioritizing of prevention.
OK, you’ve convinced me.
Until this morning, I’d been on the fence but leaning toward favoring President Obama’s ideas for health insurance reform.
Having read your op-ed piece, I’ve decided it has to be defeated.
You are the very model of a plusgood doublespeaker, if I may juxtapose my allusions. You say you are not, of course, talking about euthanasia when in fact, of course, you are. True, you don’t suggest sending out death squads on people’s 85th birthday, and I suppose we should be grateful for small favors. But you do suggest denying them the financial lifeline that will keep even healthy people alive–Medicare. In short, you would pay for universal access to affordable health insurance with the universal *denial* of affordable health insurance to the portion of the population you disfavor. Plusgood doublethink, Mr. Dooling.
President Obama said only last Saturday that no one wants to pull the plug on grandma. I guess you’ve figured out the way around that. You wouldn’t let anyone put the plug in.
My mother is 87. Her father lived to 101. She’s in good health. She lives in an unassisted living retirement community. Her only hospitalizations in recent memory have been for (successful) glaucoma surgery. She currently takes only one (1) medication.
But she does go to doctors and dentists for the same type of routine care you would, and my brother and I are not wealthy. We depend, as she does, on Medicare to pay for the routine care that maintains her active and productive life. I suppose we would have found a way to pay for the care that allowed her to keep her sight and her independence, though I can’t see how.
But that’s not your lookout, is it, Mr. Dooling? She and those like her are simply, unavoidably outside the community of worthy of concern and protection. In other words, let them die, and decrease the surplus population.
You, Mr. Dooling, are an ice-hearted monstrosity, a death’s-head in the guise of a humanist. And that guise is the real danger of health care reform–that it will allow the availability of health care to be determined by individuals who are willing to enact their personal ideas about who is worthy to receive it. To hell with that, Mr. Dooling, and while we’re at it, to hell with you.
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