The meter’s always running in the death cab
Who really benefits from the prolongation of a dying person’s life?
A friend and former colleague of mine is very sick. Several months ago, he suffered a massive stroke caused by the explosion of a blood vessel in his brain. He was first taken to a local hospital in Plumas County, then helicoptered to Reno, and then, when the facilities there weren’t adequate to the needs of his condition, flown to San Francisco, where he has been ever since.
He came out of his coma after a few days in intensive care, but he has battled infections and a roller coaster of ups and downs. He spent three months in a Bay Area ICU before being placed in a nursing home, and his prognosis is not very good.
He is 68 years old, a retired English teacher and community college administrator, and the thing I can’t make sense of is the cost/value/benefit ratio of the care he’s been given. In the last couple of months, more money has been spent on my friend than he earned over the course of his entire lifetime. All the money for food, cars, gasoline, property taxes, shoes, haircuts, and mortgage payments earned over the period of a life’s work doesn’t equal the millions spent to keep him alive since he suffered that lightning bolt to his brain. All the money he spent raising his daughters, all the money he earned by grading 10,000 or more student papers and delivering hundreds of lectures, does not equal the money that has come his way through the medical system over the past few months, when he is incapacitated, when his prognosis is poor.
Should he make even the most optimistic recovery one could hope for, his quality of life will still be seriously compromised. His life will have been extended, but to what benefit, and at what cost?
The whole business (and there’s surely a business element to this scenario) has me deeply puzzled. Obviously, to my friend’s wife and family, no amount of money spent is too much money if there is even the slightest chance he may recover. And I, too, at a greater emotional distance than his relatives, wish for that recovery, and would relish the prospect of having him once more at my table, sharing stories and music and memories of times gone by.
But there’s something about all of this that makes no sense. For all intents and purposes, my friend is gone. The man I knew, and the man he saw himself to be, will not be joining that convivial table conversation. Not now. Not ever. So much of what is being spent on him now is really an investment in denial and false hope.
Nearly 10 years ago, I experienced a similar scenario when my father suffered a stroke and sank into a coma from which he never emerged, though he was kept in a kind of vegetative state for some six months, most of it at a Veterans Administration hospital.
There the doctors supported their rather lavish lifestyles by making daily visits, poking their heads into his room, checking off a box to show they’d been there, then going on to do the same thing with a cadre of other doomed and hopeless old vets whose lives had been reduced to providing a flow of charges to the VA, all of which were extremely (and obscenely) profitable to a legion of pharmaceutical firms and for-profit care providers. Every time those doctors checked that box on my dad’s chart, a bill was sent and a rather sizeable check was issued to a doctor who did almost precisely nothing.
My dad was being harvested by the system, his helplessness exploited in ways that benefited him not at all, but benefited the vultures who offered their tender mercies at very high prices.
During a visit to his bedside, I finally cornered one of those doctors for an assessment of what was going on as Dad fought off one infection after another, all while in a fugue state that left everyone who loved him speculating as to where he was, what he understood, and how much of him was left. Was there any prospect of getting my dad back, I wondered, and if not, why did the doctors continue to treat the series of respiratory infections that had plagued him since the stroke?
At this point the doctor said, “We’re just putting out fires.”
“But why?” I asked.
“Well,” he said, “no one’s told us not to.”
And so my old man, who risked his life for his country in World War II, and who worked hard in a series of dead-end jobs, and who raised his kids and never asked for nor received a dime he hadn’t earned, was, in his last powerless days, repaid for his service to his country and his years as a taxpayer by a gusher of cash that did not benefit him in the slightest, that prolonged his family’s anxieties and miseries, and that enriched lots of people who lived lives my dad could never have even imagined—beachfront property, cruises and luxury golf resorts, all paid for by vets who earned those medicos such largesse simply by growing old, getting sick, and becoming utterly powerless to stop such exploitation.
I know it’s not simple. We have developed the knowledge and the technology that allow us to keep people alive, often pointlessly. Even when doctors are not influenced by the money that comes to them through ministrations to the hopeless, they are sometimes driven by egos that make them reluctant to admit the limits of their powers.
Most of the past year has been spent in a national bout of wrangling over rather niggling changes in our health-care system. What has been absent from that debate is a serious attempt to reckon with the moral, pragmatic, and existential issues that attend late-life illness. When we say our present system is riddled with waste, it cannot be denied that much of the waste occurs on overpriced services and procedures performed on people who benefit very little from those expenditures.
After all, who wants to say what may need to be said at such a critical moment?
And so the meters keep running in cash cabs that aren’t going anywhere at all.