Talking About Hard Truths And End-Of-Life Care
Guest post written by
Dr. John Maa
Dr. John Maa is past-president of the Northern California Chapter of the American College of Surgeons.
The cost of end-of-life care jeopardizes the
long term viability of Medicare. The Centers for Medicare and Medicaid
services estimates that more than 25 percent of Medicare spending is
directed to the 5 percent of beneficiaries who die each year, with a
third of that cost in the last month of life.
The health reform debate
in America has been hampered by a lack of progress about end of life
care and medical futility. The following story may offer a new starting
point to restart the dialogue.
One day on call I was asked to evaluate a patient with stomach cancer
for resection. The patient was an 82 year old woman, who was bundled in
blankets with two of her adult children at her bedside. She did not
speak English, and I obtained her history from the children, who
provided translation.
She had been diagnosed months before with a stomach cancer. She had
already undergone chemotherapy and radiation at another hospital. But
the doctors felt that her situation was too advanced, and as the tumor
had not responded to treatment, that further surgery was unlikely to be
helpful.
So the family requested transfer for a second opinion. I was now
being asked to attempt palliative surgery for local control. As I
removed the blankets, I noted she was quite emaciated, and had a firm
palpable mass in the left upper abdomen. After I completed the physical
exam, but before I could offer my opinion to the patient, the children
asked if they could speak with me outside of her room.
The children shared that they did not want their mother to be told
she had advanced gastric cancer. I was asked to attempt surgery, and to
only tell the patient that we had placed a feeding tube for nutrition,
but not reveal the cancer diagnosis.
I wondered how the family and doctors at the other hospital had
explained the need for chemotherapy and radiation without disclosing the
truth to the patient? Caught by surprise, this request made a complex
situation even more unclear. We returned to the bedside, and I briefly
explained to the patient that I would review the xrays and return the
following day with further recommendations.
Not disclosing the truth to the patient seemed unwise.
I pondered
other options:
1) Decline to participate in the care of this patient,
and refer her to a colleague who might be willing to honor the
children’s request.
2) Return with a translator and explain the full
truth to the patient.
3) Contact the ethics committee.
4) Concur with
the recommendation of the doctors at the referring hospital and decline
to offer an operation.
Ultimately, I chose a different option. I returned the next day, and
stated to the children that their mother might wish to know the truth
and spend her remaining days outside of the hospital enjoying life,
rather than undergoing possibly futile treatment. I indicated that I
would be willing to perform an operation in an attempt to remove the
tumor, and would place a feeding tube if resection was not possible. I
would leave the decision to the children to inform their mother of the
operative findings. However, I also indicated that in my opinion the
ethical action would be to tell her the difficult reality of the
situation, and that surgery would be unlikely to impact the final
outcome.
After a lengthy discussion, the children chose to tell their mother
the truth. She made the decision to decline further treatment, and
travel the world. I saw her a final time before she left the hospital,
and with them translating, she thanked me for convincing her children to
reveal to her what she had always suspected to be true. Perhaps the
time has arrived for America to honestly and intelligently discuss
health care rationing and end of life care to save Medicare?
John Maa M.D. is past-president of the Northern California
Chapter of the American College of Surgeons. In 2009, HealthLeaders
Magazine named his as one of the top “20 people who make healthcare
better in America.”
Opinion