The elephant in the room

By Karen Sibert 26th February, 2012

One of my partners recently sent out a call for an extra pair of hands to help out in the operating room—and with good cause. The patient on the OR table was a woman in her 60’s whose massive stroke had left her hemiplegic, aphasic, and unable to swallow. She weighed well over 400 pounds. Attempts to place a percutaneous endoscopic feeding tube had failed due to her size, and she was now scheduled for open gastrostomy tube placement under general anesthesia.

Even with two experienced anesthesiologists working on the patient, getting vascular access and an endotracheal tube in place wasn’t easy. She was anemic for reasons that weren’t fully worked up, and her blood pressure was alarmingly labile. At the end of the procedure, the patient couldn’t be safely extubated so she went to the ICU. As it turned out, she never left. The family couldn’t agree on any reduction in the level of life support, and after a stormy five-week stay, she finally expired. The cost must have reached hundreds of thousands of dollars, and all was spent on sustaining a patient who had no hope whatsoever of meaningful recovery.

This is really the elephant in the room in all the endless talk about health care costs in America, and it’s a subject that often is considered taboo: the amount of money that we spend fruitlessly on end-of-life care.

I am not talking about comfort measures, hospice care, palliative medicine, or any of the other valuable support functions that ease the process of dying. I am talking about using the full technical and pharmacologic armamentarium available in our tertiary care hospitals to treat people who cannot be restored to health.

In anesthesia, we see this problem every day. As consultants, we are not involved in the decision-making process, but we are the ones responsible for getting desperately ill patients through a variety of diagnostic and therapeutic procedures. There are days when not a single patient I look after is likely to survive six months, or in some cases, ever to leave the hospital.

Some procedures are palliative and are justified on humanitarian grounds alone—talc pleurodesis for recurrent malignant pleural effusion is an example. Others are more questionable. How many lung biopsies on ventilated ICU patients ever lead to a diagnosis that changes the treatment plan and improves the outcome?

I bet nearly every anesthesiologist at some point has asked himself the question, when faced with a terminally ill patient, “Why are we doing this?” Sometimes the answer is that the family is pushing to have “everything” done—out of loyalty, guilt, or an inability to face the inevitable. Sometimes it seems that the primary doctor is casting about to find something else to offer as a treatment, whether or not there is much likely benefit. Once everyone else has agreed that the procedure will be scheduled, the anesthesiologist hesitates to put any roadblocks in the way. Raising any objection will only upset the family. And, let’s be honest—in a fee-for-service system, cancelling the case will deprive both the surgeon and the anesthesiologist of income.

Lately there seems to be a little more intelligent discussion about the millions of dollars we are spending on patients in the last months of life. Dr. Atul Gawande published a thoughtful article titled “Letting Go” in the August 2, 2011 issue of The New Yorker magazine. It focuses most on the experiences of relatively young cancer patients, and the difficulty of balancing quality of life and heroic treatment. Looking from the anesthesiologist’s point of view, however, we see a different angle. Many of our aging patients suffer from chronic problems that compound to the point where meaningful recovery is improbable. At what point does it become unreasonable to pursue further aggressive, costly treatment with stents and AICDs? Should intensive care units continue to evolve into pre-mortem holding wards?

One of the saddest facts about the health care reform bill is that an important provision was deleted in the final negotiations: one that would have allowed Medicare to compensate doctors for time spent with patients and families to plan for end-of-life care. In the public hysteria over “death panels”, this provision was dropped. However, time-consuming counseling is critical so that patients and families can truly understand their options. The fallback position is to “do everything”, and waste millions in the process.

If anesthesiologists never speak up, are we doing our job as physicians? Or are we ignoring the elephant in the room, and furthering the uncontrolled consumption of medical care at the end of life? There is only so much money available to support health care services, and it needs to be spent as wisely as possible.

Karen Sibert is Associate Professor of Anesthesiology at Cedars-Sinai Medical Center in Los Angeles, CA and blogs at