When 75-year-old Frederick McCoy entered a Baltimore hospital suffering from an inflamed pancreas, a failing gallbladder, a weakened artery near his heart and Alzheimer's disease, his family made one wish clear: No surgery.
With his approval, they reasoned it was time to let his body quit on its own schedule rather than to prolong a life in which he was increasingly sick and so forgetful he would read a newspaper four times without realizing it.
So what happened? Suspecting that his artery had burst, doctors floated the idea of a surgical repair. The family said "no."
Pop knows he's failing. He doesn't want us to do anything. He's bleeding internally, not an unpleasant way to die. Let's just ride it out.
That's how his grandson, Dr. Mark E. Bohlman, remembers a conversation among family members. But the doctors, unaccustomed to watching a patient die from a repairable injury, convinced Mr. McCoy's daughter via telephone to consent to surgery. In the operating room, the surgeons discovered the artery was intact, but decided to remove his diseased gallbladder as long as they were "inside."
Five days and tens of thousands of dollars later, Mr. McCoy died from pneumonia in the intensive care unit. He spent the last days of his life with tubes in his mouth, nose and arm.
"Here's a case where we as a family were lobbying against doing anything, then we got the medical person on the other side saying we just can't sit by and let someone die," said Dr. Bohlman, a radiologist at the Francis Scott Key Medical Center.
Dr. Bohlman said that experience only strengthened his belief that doctors ought to weigh the likely benefits before administering aggressive therapy to patients in the last stages of life.
"If there's nothing to be gained from it, why do it?" he asked. "I think doctors just get it in their heads they want to cure people. That's what drives them. But people do die, and I think people lose track of the fact that people will die from something."
American medicine is the envy of the world for the sophisticated care it offers people with life-threatening illnesses. Increasingly, the public has come to expect doctors to push back the boundaries of life.
But as the nation grapples with the task of taming health care costs, ethicists and health economists are questioning whether the medical system squanders billions of dollars on treatments that give desperately ill people only the faintest hope of survival.
Complicating the issue is a nightmare of demographics. The elderly population, which consumes the most health care simply by being sicker and more frail, will more than double by the year 2030 as baby boomers push through their 60s and 70s, according to census estimates.
Doctors are beginning to concede that if society is serious about limiting health care expenditures, it may have to forgo expensive end-of-life treatments that offer dubious benefits.
This could mean withholding aggressive treatments for terminal patients of all ages: premature babies with lungs too small to inflate; elderly patients in the advanced stages of Alzheimer's and patients in "vegetative" states who live only because devices deliver oxygen to their lungs and nutrition to the veins.
A recent federal study revealed that 28 percent of the money Medicare spent on people over 65 occurred in the last year of life, and half of those costs occurred in the final two months. The study of 1988 data, published in last week's Journal of the American Medical Association, noted that the percentages did not climb as many analysts suspected -- but held steady over a 12-year span.
Nobody knows what the ideal proportion is, but many doctors believe current spending is too high in light of such unfulfilled needs as preventive health.
"We've never learned to say 'no.' We've been taught that any patient can recover," said Dr. Marc C. Rogers, the former chief of critical care medicine at Johns Hopkins Hospital. He is now the chief executive officer at the Duke University Medical Center.
"I don't believe it will be possible to save money in the intensive care environment without giving up some benefits of care, including the ability to say I want everything done regardless of the cost."
What if we try this?
Pressures to extend life seem to come from all corners.
Families have blamed doctors for racking up fees with burdensome treatments heaped on dying relatives. Some critics accuse a medical education system that places a premium on treating disease rather than the whole patient, emotions and all. And physicians tell of desperately ill patients who have begged for treatments that offer a slim chance of gaining a couple of months.
Doctors say they agonize over the ethical dilemmas posed by patients who seem near the end of life but could possibly rebound with last-ditch treatment. They concede they sometimes harbor regrets when they go too far.