the day I realized I was part of the health care spending problem

I rang in the New Year on call.


When the clock struck midnight, I was the attending physician for the nephrology consult service for patients in the hospital. But no need to feel too sorry for me—being on call as the attending is nowhere near the pain of being on call as a fellow in training.


As the renal fellow on call, I returned pages to answer questions and went into the hospital at any hour of the night to evaluate patients with urgent kidney issues. As the renal attending, I just needed to be awake and sober enough to hear the fellow talk about said patients and ensure her diagnosis and treatment plan are on point.


Yet, even as the attending, I still find being “on service,” the most painful aspect of my job.  It hurts because of the steady presence of old patients who tried to die outside the hospital, but were resuscitated to the point of being “technically alive”— with the help of a ventilator to support the brain that could no longer trigger the basic function of breathing and maybe an IV pressor medication or three to support a failed heart and very low blood pressure. And of course, slow continuous dialysis for failed kidneys in a person who can’t get through the intermittent dialysis— the usual thrice weekly, 3-4-hour treatment that our maintenance dialysis patients receive, with blood flowing through the dialysis machine nearly twice as fast as the slow continuous kind of dialysis—without their blood pressure dropping too low for pressors to bring up.


I find these patients painful because they represent health care waste.  The kind of waste that explains why the US spends more than twice as much as all other comparable countries on average, but has the highest rate of death. The kind of waste that results from putting individual wants ahead of population needs because there is no hope of “meaningful recovery.” These patients will never return to the awake and talking and possibly even walking person they were before the tragedy struck, no matter how hard family prays and hopes for a miracle. But instead of diverting dollars spent on this care to preventing disease, we routinely allow weeks to pass while we wait for rarely seen or even estranged family members to gather from hundreds and hundreds of miles away to dictate whether or not the occasional eyelid flutter or finger twitch that defines technically alive is meaningful enough.


At this point the decision is made to either transition from machine care to comfort care or to double-down with a trach and PEG—a tracheostomy, a breathing tube through the neck into the windpipe, and a percutaneous endoscopic gastrostomy, a feeding tube through the abdominal skin into the stomach. The trach and PEG were needed in order for the technically alive person to be ventilated and fed in a long-term care facility full of other technicallys, awaiting their miracles too.


This is why I tried something different when faced with technically alive Mrs. P during this last stint on service. For weeks, she had been on the ventilator, a pressor, and slow continuous dialysis with no sign of brain recovery beyond a flutter or twitch. As she awaited family to come in and decide if trach and PEG would be her fate, I made what I thought was a bold by mouth that helps keep the blood pressure up. My rationale was simple: One cannot go to a long-term care facility on a pressor or continuous dialysis. So if Mrs. P couldn’t tolerate intermittent dialysis without a pressor, there would be no need to put her through a trach and PEG. Rather, this would be the “end of the road” of invasive machine medical treatment that neither family nor doctors would have to feel guilty or argue about. And Mrs. P would be allowed to pass away over the next few minutes, hours, or possibly days without our tubes and machines. I felt joy in my courage of going against the usual course.


But when, to my surprise, Mrs. P did tolerate the intermittent dialysis, I had to ask myself why it hadn’t even occurred to me to say, “This patient is not appropriate for maintenance dialysis, so we should stop the slow continuous dialysis too”? 

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