Medical Overkill


February 02, 1993|By ELLEN GOODMAN

WASHINGTON — Washington. -- It is late at night, and we are talking about health care the way Americans do, in personal stories that begin with words like, ''my mother'' or ''my friend'' or ''I.'' This time we are talking about the end of life. How it often ends. How we would choose it to end.

In the last months we have borne witness to two deaths, two technological grand finales to good humane lives. Two men we know went out of life in full medical regalia -- tubes and respirators galore -- like some horrifying fireworks display of What Medicine Can Do, Circa 1993.

One of our friends has, in her hands, a hospital bill some 70 pages long and $200,000 insurance dollars deep for her brother's last month of what barely qualified as life. Another colleague is trying to tally up, just for the macabre curiosity, what Medicare paid for her husband's last days: the cost of coma.

Their mourning and our evening is made uneasy by the feeling that maybe too much had been done to these men in the guise of doing everything for them. There was a point, somewhere in the dying process, when medicine took over, when one decision led to another inexorably.

We share other such stories of times when all thought-out plans, all the family discussions, had simply been finessed, short-circuited by the hospital imperative to do one thing and then another. The medical people had gone step by step down the road to the respirators.

Our conversation this night is not just personal though. It's colored, I am sure, by the recognition that a new man has moved into the White House not far from where we sit. He has promised a new health care policy as part of his hundred-day hit parade.

Two sets of words come together, one after the other, as if they were inseparable: Health care and hard choices. But the truth is that we haven't even been able to make the easy choices yet.

One thing we know is that the costs of health care went up some 14 percent last year. We know that over a third of all Medicare expenses go to the treatment of people in the last months of their life. Whether they want it or not.

There are studies that echo our personal conversations. They show that Americans worry that at the end of life they will receive too much medical treatment and too little pain relief. Now there is, as well, a survey that says doctors and nurses who treat dying patients worry that they give too much treatment and too little pain relief.

Health-care providers who answered the survey by the Education Development Corporation were four times as likely to be concerned about overtreatment as about undertreatment. Half of them said they had acted against their conscience in providing health care: They had offered treatment that was ''overly burdensome'' to patients. Two out of three believed that patients didn't get enough help or information to make decisions.

So we have some rare agreement between patients, families, doctors, nurses, even ethicists that the terminally ill should be treated with fewer tubes and more tenderness than is often the case. But still the stories accumulate. And so do the costs.

To mention money is to be immediately suspect. As Susan Wolf, an ethicist who helped with the survey says, ''The cost-containment argument makes people suspicious that there's a hidden motive behind stopping life-sustaining treatment. That it's not just about effecting the patient's wishes.'' It raises the specter of an accountant behind the physician deciding who lives and who dies.

Nevertheless, when we talk of health care and hard choices in the same breath, we mean medicine and money. We mean the allocation of dollars to transplants and prenatal care, to the elderly and the young, breast cancer and AIDS. We envision groups competing with each other for attention and dollars.

The stories of medical overkill of the dying are about times when the ethical and financial bottom lines might converge. They represent moments when doing what is humane also saves money.

If we cannot stop treatment for those who don't want it, if we can't respect the wishes of the dying and their families, if we can't make the easy choices, what hope do we have to make the rest?

These are decisions that will take place not just in one, white, house but in a hundred hospital rooms a day.

People are forever asking, where do we start the debate about health care? One place to begin is at the end.

Ellen Goodman is a syndicated columnist.

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