What's really killing grandma

For the next week I will be on vacation, so my posts may be less frequent and possibly more relaxed.

This Republican fear-mongering about healthcare reform killing grandma is really burning my butt: I have delivered "everything", I know what "everything" looks like, I know its dark side. I also know that they are spreading deliberate and self-serving lies to bring Obama his Waterloo, and that these lies will ultimately hurt not only grandma, but the rest of us as well. Let me tell you what I mean.

When I was in clinical practice I cared for critically ill patients in the intensive care unit. I entered this subspecialty of internal medicine for several reasons, some cerebral and others humanistic. For example, I could not get enough of the physiology gone awry that explained so much of what was happening to my patients; sometimes by supporting them through the insult I was able to pull them away from the precipice, at other times I failed. My humanistic impulses were satisfied by giving the families much needed support and hand-holding through what were probably some of the most difficult and unclear moments of their lives. Unfortunately, my practice afforded me many opportunities to gain an appreciation for the pain and frequent futility of the prolongation of a life that is likely to lack in quality downstream from the critical illness episode.

Countless times it is the intensivist, as the critical care doctors are known, who is the first to address end-of-life issues. The scenario frequently goes like this: an elderly patient is hospitalized with a pneumonia or another acute problem. The primary care physician, with a long and meaningful history with this patient, has never asked her what her wishes are should she require heroic interventions, nor has she shared her wishes with her family. In fact, it is possible that she has not even thought about it herself, despite her chronic health problems and advanced age. So, now she is on a ward and is unfortunately deteriorating despite appropriate care. Now the intensivist is called because the patient is having trouble breathing and looks like she will pass on if not given immediate help from the ventilator. The intensivist, who has a relationship neither with her nor with her family, now has seconds to minutes to make a very difficult choice of whether to commit this patient to an extreme course of treatment. The family when consulted of course opts for "everything" without a clear understanding of what that "everything" entails.

And herein lies the power of the Republican fear-mongering campaigns asserting that Obamacare will be killing your grandma. A rational approach to medical decisions through comparative effectiveness research and IPAC recommendations is anathema to their entitlement to doing "everything". What this "everything" looks like for your beloved grandma can and should strike fear into your souls. It includes days and even weeks on a ventilator delivering breaths through a plastic tube going from her mouth into her lungs via the trachea, eliciting an exuberant and constant gag response and other untold discomforts. If you have ever seen someone getting intubated (the breathing tube getting put down the throat), you have seen their horror and discomfort. So, to keep grandma from willfully pulling her tube out and damaging herself, she is kept under constant sedation, except for being awakened once daily to make sure that she is still neurologically intact and to assess her readiness to breathe on her own. Depending on how sick she is and what flavor of "everything" she requires, she may need even to be paralyzed in order for the ventilator to do its job. And the tube is only the beginning. Many patients will need additional uncomfortable and invasive daily interventions, the questionable value of which for grandma's recovery may not become clear for many days.

And then there are complications of the ICU stay. If you believe the propaganda that modern medicine, through adopting processes practiced by the airlines industry to eliminate human error, can eliminate all hospital-acquired complications, I have a bridge in London to sell you. The obvious but conveniently ignored truth is that the sicker the patient, the higher the risk of complications not because of anything humans do but because of the severity of her illness. So, even if grandma is able to get through her acute pneumonia, she is now at risk for such complications as a secondary ventilator-associated pneumonia, infectious colitis with diarrhea, and many others that the public is mostly naïve to until they encounter them during grandma's hospital course.

The gut-wrenching decisions come several days into "everything", when it turns out that grandma's heart, after years of coronary disease, is only working at 1/3 its capacity and not pumping enough blood to her vital organs, and her lungs are working even worse, and now her kidneys are shutting down, and she is developing low blood counts and you, the family, have to make decisions about invasive heart tests and transfusions and dialysis and all sorts of other stuff. And at this point I, the intensivist, have to tell you, the family, that grandma is not likely to survive her hospitalization, and to continue "everything" is at best counterproductive and at worst harmful to her. And even if she does recover from this insult and survive the weeks of critical illness, she is not likely ever to go back to her independent life at home, and, in fact chances are she will be dead within the year. So now, you, the family, have to decide what to do: do you keep grandma on "everything" in the hopes that she recovers in the short-term, knowing that we are consigning her to a short and quality-free remainder of her life, or do we cut her losses and make her comfortable with drugs and let her drift peacefully into Lethe by having me the intensivist stop "everything".

These are scenarios I was confronted with daily when I was in practice. These are scenarios that my colleagues, patients and families deal with every day across our nation. These are the scenarios that the conservative propaganda machine is pushing on you, the public, by propagating lies about "everything" and its disappearance under the healthcare reform. I believe we want "everything" because it has been sanitized for us by the media echo chamber and we do not see its horrors until it is too late to prevent them. It is an outright blatant lie that an honest discussion about end-of-life care will amount to killing grandma. It is a lie that doctors want to euthanize their patients in order to save money. If we believe the lies, we are even bigger idiots than they give us credit for and, we deserve "everything" we get!