15 Sep When Less Is More
By Noura M. Dabbouseh, M.D.
We speak of everyday decisions in terms of “cost-benefit” analyses. Many of our patients can’t afford a healthy meal, let alone a hefty hospital bill, thus making cost awareness increasingly relevant. But on the day that I met Mr. R., it wasn’t the financial aspects of his care that concerned me. I was thinking about the patient, his family, and two roads diverged in a hospital ward. I was thinking of the road less traveled, and the greener pasture oft overlooked.
Mr. R. was a 70 year old male smoker with high blood pressure and the diagnosis of congestive heart failure made one year earlier. For a year, his condition continued to decline. His family, consisting of 6 members, banded together and brought him into the ER at the hospital where I work one night to seek a second opinion for his weight loss of 100 pounds over three years, confusion, and lack of appetite. He was admitted by the ER for these findings and because blood work showed slow kidneys.
We evaluated Mr. R.’s heart function with an ultrasound, which showed an extremely weak heart that was likely the result of chronic alcohol use. For his confusion, the neurology team was consulted, and they recommended brain imaging with contrast dye. While evaluating for an ischemic cause for a foot ulcer he had, Mr. R was found to have an abdominal aortic aneurysm, or AAA. Vascular surgery recommended immediate repair, as it had a high risk of fatally rupturing. The attending vascular surgeon, however, also cited a study that determined the patients with as many medical problems as Mr. R. did not generally live longer with surgery than without surgery.
I spoke with Mr. R’s wife. She listened intently as I answered questions about his current condition. I then made my recommendation for hospice and I’ll never forget our conversation.
“Are you saying there’s nothing we can do?” she asked.
“No,” I replied. “I am saying there is a LOT that we could do. I just don’t think we should.” I based my recommendation not only on his likely Alzheimer’s dementia – normally a clinical diagnosis, though his head CT was read also suggested this – his end-stage heart failure, and his poor kidney function, but also on the fact that he was functioning at quite a high level in spite of these diagnoses. Further imaging tests that involved contrast dye (such as those recommended by both the neurologists and the vascular surgeons) would put him at great risk for being dialysis-dependent. More importantly, my team did not believe any of these tests would prolong or improve the quality of his life. His AAA would be extremely risky to repair, given the nature of the procedure and his poor heart function. I was concerned that, were he to undergo the surgery, he might not make it out of the hospital or even a hospital bed on his own ever again. I stressed my uncertainty in these predictions and I mentioned that patients do better than expected all the time. The decision was hers.
To her, the choice was clear. She wanted her husband to go home with hospice and spend as much time with his family while maintaining the most independence possible for as long as possible. This was arranged. I called Mrs. R. a few weeks later. Her husband was doing well, she reported, and continued to eat and sleep well and walk daily. She was at peace with her decision.
We walked the path less traveled. We exercised cautious restraint in considering Mr. R’s care. Going the costly, aggressive route, I’m convinced, would have caused more harm than good. In regards to quality of life alone, conservative management was the clear winner in the cost-benefit analysis. And it just happened that it was the less expensive winner: no MRI, no MRA, no AAA repair, no ICD, no ESRD or HD, no ICU, and no excessive diagnosis codes that included any of these acronyms that we far too often see in a patient’s chart toward the end of life.
Noura M. Dabbouseh just completed her Internal Medicine residency training in Chicago, and is pursuing additional training in a fellowship program in Wisconsin. She was also a contestant in the 2013 Costs of Care Essay Contest.