Thirty percent of an individual’s Medicare expenditures in the United States are spent in the last year of life, numbers that are very similar to here in Canada. This, in my opinion, represents a fundamental flaw in our medical economic system and culture. As a soon to be critical care fellow at McMaster University this phenomenon is very evident in my day-to-day practice. Cutting edge medical interventions, heroic measures, and life support systems although incredible in their potential to extend survival are not appropriate for application to all patients. This is where the most evident of misconceptions exists for a good proportion of the general public. Although we have the ability to intubate your 96-year old mother and send her to the intensive care unit (ICU) on a ventilator and initiate hemodialysis for her renal failure does that mean we should? This ethical conundrum is one that comes up repeatedly in hundreds of ICUs around the country each day.
Futility of care may be obvious to the seasoned critical care physician but to the family experiencing this situation for the first time their only prerogative is extending their time with their loved one, not necessarily focusing on the quality of this borrowed time. Physicians act objectively, substitute decision makers (SDMs), often lacking malice, more easily get overwhelmed by emotion. Physicians are able to see that “doing everything” with little hope for a meaningful outcome can on a larger scale impact our tenuous healthcare economics. As an example an ICU bed alone costs the health care system around $2500 per day when physician and nursing fees are included. Tying up medical resources in situations where they are not best used may prevent them from being available for the situations where they are most needed. These disagreements between the treating physician and the SDM concerning end-of-life care are probably the most difficult challenges faced by most intensivists on a daily basis. In contrast, the management of medical issues such as electrolyte disturbances, low blood pressure or severe infections seems straightforward.
So how best to resolve these discrepancies that can exist between SDMs and the medical team? In these emotionally charged situations tensions often run high. Conflict can easily erode the important therapeutic relationship between the physician and patient’s family ending any hope for mutual resolution. Legal intervention, although an option, hardly ever brings closure. A recent case at Sunnybrook hospital (Rasouli vs Sunnybrook Health Sciences Center) involving just such principles went all the way to the Ontario Court of Appeal with a final decision that offers little in the way of precedence or guidance to families or physicians. I have heard and understand the “slippery slope” argument. Allowing physicians, hospitals or governments to dictate end-of-life care could be a dangerous precedent. Families and SDMs need to be included in the process, patients’ advanced directives (if present) need to be considered and consensus should be the goal. That being said, our current structure is not sustainable. We need to work better as a society and as a medical community ensuring that the medical care we provide, especially in the setting of end-of-life care is not only state-of-the-art but practical, economical and therefore ultimately in the patient’s best interests.