I was a medical student on an EM rotation in the 1980s when I first heard someone say it. EMS brought in an old man from a nursing home with sepsis. He looked like thousands of similar patients I have seen over the past 25 years. Strokes left him bedridden with decubiti and contractures. He was nonverbal, and his mental status declined with his blood pressure. He was one of my first experiences in dealing with the acute presentation of nearly dead.
What followed was one of those typical experiences I read about in personal statements every year from applicants. They usually go into detail about how they witnessed emergency personnel work together in synchrony to defeat death. The residents in my story jumped all over this guy. He was intubated with a central line and antibiotics in minutes. That's when I heard it. The attending leaned over to me and muttered under his breath, “We're all going to hell for this.”
I discussed in my last column (http://emn.online/AfterMatchEMN) how the intersection of politics and health care advances created a metaphorical tsunami for those in the business of making sick people better. We are drowning in regulations, rules, and astronomical cost, but we continue to extend lives in ways that are brutally unnatural. It's no secret (except, it seems, to the public) that we can do some pretty mean stuff to patients. I am amazed at how many times we cause pain for people unable to make decisions for themselves. It's one thing to make a sick child cry by starting an IV; it's another to marinate vegetative patients in antibiotic cocktails for another case of infected urine. We may roll our eyes or come up with a clever quip, but it does cut into each of us a little bit every time we do it.
A few years back, we had a geriatrics seminar at one of our weekly resident conferences. We had a panel of elderly citizens from the community attend to answer questions about what they expected from the emergency department if they needed treatment. All of them were retired from middle-class professions, and all were more-or-less healthy. They were asked whether they had a living will or power of attorney. Only one raised her hand. As it turns out, she spent her career working in administration for our hospital. All of the others just did not want to think about it. They all seemed to fear losing control intensely, even when it potentially obligated us to do unpleasant things to them.
Our national political discourse is even worse. Any mention of rationing care or encouraging physicians to discuss end-of-life strategies degenerates into the incredible rhetoric of death panels and playing God.
What to do? My suggestion to emergency medicine residents now is to leverage your education to become part of the solution, and the reason this might work is a common one: money.
If you look at this from an economic standpoint, it is basically a supply-and-demand problem. We have too many demands for overzealous health care in a system that will not be able to provide it for everyone. You can increase supply by increasing efficiency. You can also lower demand, particularly when so many people are demanding things they really do not want.
It is inevitable that smart health care organizations will invest in people who can do this, and the big driver is capitated health care reimbursement. Basically, you can only get paid a specified amount per patient per disease. The cost of meeting every demand related to end-of-life care is not affordable, and trained physicians are needed to develop systems that educate patients on how to avoid unwanted therapies when they are incapacitated. The bottom line is that skills in palliative medicine will have the potential to avoid unnecessary suffering and save billions of dollars.
I know what you are thinking: Cook has lost his damn mind. You are in emergency medicine because you want action, not hospice care and nursing homes. But it is the person who can see synergy in dissimilar things that can change paradigms and find success. I have written before on how diversifying your talents now as a resident can improve your long-term professional satisfaction. The problem of meeting end-of-life care demands will only intensify, and you might be the person everyone wants to help with this problem. Emergency medicine has made its mark by filling vacuums of need. Few areas in health care today are in greater need of talented people than the one that provides reasonable alternatives to extending the lives of people who want something else.
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