Economics of terminal careWhere has Dr. Douglas Carroll...


January 13, 1996

Economics of terminal care

Where has Dr. Douglas Carroll been while medical journals have openly discussed what is now known as "futility care"?

His Jan. 1 letter suggests that the medical world or patients' families are totally unaware of anguish and sorrow, confused decision-making and expenses connected with clearly terminal medical care.

Futility care has been named, identified and debated in major medical journals over these past several years.

Too often in ruminating about the costs of surgical or medical care, Medicare or the federal dollars available to persons over the age of 65 are referred to as a major source of excess spending.

Phrases like "dollars spent in the last six months of life" and references to "caretakers or the patient's own family" suggest that terminal care is a fault of elderly people who don't really need or deserve another six months of living.

Pragmatists forget that those last months of care -- no matter how many or how few -- can many times only in retrospect be considered terminal or futile.

Intensive care may be brief for patients with gunshot wounds, severe infections, vehicular accident injuries or suicide attempts, but need not be futile.

Ages of patients who receive terminal care may range from those of premature infants to centenarians.

Would Dr. Carroll or any other physician want to terminate intensive care simply because it may be terminal -- or maybe not cost effective?

This debate over costs or expenses for health care should not separate public Medicare and Medicaid and private insurance spending for surgical and medical care.

All of these dollars go for health and sickness care and have been provided by John and Jane Q. Public.

They are spent in accordance with public rules and regulations developed by government officials, insurance company executives, company officers and union leaders.

To suggest that only government payments for Medicare's elderly care in the last six months of a long life are excessive is absurdly simple.

High costs occur in the last six months of life at every age. One must consider all of the elements that contribute to the increasing expense of quality care and either improve care efficiency or reduce care costs -- not abolish compassionate care at critical times.

John B. De Hoff, M.D.


I commend Dr. Douglas Carroll for his courage in stating what is obvious but seldom openly discussed: the all-too-high cost of dying.

How many other health care providers feel the same way but hesitate to openly mention it?

Decisions regarding the allocation of resources need to be made. Maryland should begin this discussion in earnest.

Changes can be made, though they require pressure from the non-medical community. Witness the support which the medical community now gives toward curtailing smoking.

This change in attitudes has taken many years. Why? Could it be that a major proportion of the lingering deaths which represent the high expenses and profits mentioned above are frequently smoking-related?

Surely, the surgeon general was not the only person to make the connection between smoking, illness and death, regardless of what the cigarette manufacturers said. No, the change in attitudes is clearly the result of social change which forced the changes in the medical establishment.

Some studies, Dr. Carroll wrote, "estimate that over 50 percent of all health care is spent on intensive care and testing on patients whose own caretakers think have little chance of benefiting."

This is significant. He is quite right in suggesting that such resources could more effectively be spent in preventive, prenatal or early childhood medicine.

When preventing problems becomes a cost-effective move, as it is in business, changes in medical delivery will occur. With medicine becoming centered around competing HMOs, hospital groups, etc., this shift to preventive medicine will also come.

At that point the balancing tensions between what is "good medicine" and effective economics should be interesting to watch.

A wise physician and friend once remarked that a doctor's role at the end of life is to make the patient as comfortable as possible and to let nature take its course. Until the course of nature can be changed and the end is no longer inevitable, we need to clearly define how we use our resources to the greatest medical good.

Edward D. Crook


Numbers alone have no meaning

I read with interest your Dec. 24 Business section article, "Debating atients' rights and state's need for data," which described the attempts of the state to garner information regarding "medical costs."

I think that someone needs to point out that all members of the committee advising the state Health Care Access and Cost Commission are drawn from the world of academic medicine and research, from one governmental agency or another or from law firms. There appeared to be not a single actively practicing physician or ordinary patient on this committee.

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