Many ethicists (especially those familiar with emergency medicine) argue there is no difference between withholding and withdrawing treatment. The point being that taking someone off the ventilator is the same as not intubating the patient in the first place. (Recall last week's challenge though: intubating in the ED may be the option that buys us time to make a decision...) Frequently, within the conversation about whether or not to withhold treatment is a cost/benefit analysis. This brings us to this week's question:
What are the costs involved in starting life-sustaining treatment in the ER?
Think both of who incurs the costs and what specific costs are involved. If you're stumped or if someone already posted your idea, refer to the four box framework for inspiration.
When a patient comes in needing life sustaining treatment, we would assume they are pretty bad off. However, with that being said many people are intubated or have other life saving treatments for other reasons then dwindling at deaths door.
ReplyDeleteInterventions in the ED are costly and can require more personal to care for the patient. I.e. an unstable patient gets intubated - anes. has to come to intubate, a stat nurse, resp. therapy, attending and usually many residents. :-)
Not using life saving treatment usually means there is a DNR, statement from patient refusing treatment, DHPOA is refusing, or there is a filed advanced directive. So I have two thoughts on why this could cost the same. First, unstable patients that do not want "life-saving" treatment can still have alternate therapies, like C-PAP, IV fluids, warming devices and an assortment of IV drugs. With an IV start at $500, Zofran (Nausea med) at $375 per dose, and C-PAP is very close to the cost of intubation and still needs RT. I am guessing that more then one physician would question the surrogate or DHPOA to confirm decision. Either with or without a vent, the patient will go the the ICU because of how unstable they are and both would require intense care. My second thought is that there needs to be a certain level of certainty in the document or DHPOA/surrogate decision - if the decision could be disputed, then that could mean a potential lawsuit.
Nutrire has pointed out the steep monetary cost - either to the patient or to the system. Thanks for those numbers. (I think Zofran is now available as generic ondansetron, but you are right about those costs being dwarfed by RT, Anesthesia, ICU...)
ReplyDeleteWhat are some other costs?
To come at this from another perspective, I would say one major cost of starting life-sustaining treatment while in the ED is you've started the patient down one path which will be all but impossible to divert away from. Starting a patient on antibiotics for sepsis or IV fluids for dehydration is paramount, but this scenario might be different for someone who is in end-stage everything disease and has spent the last two months unresponsive. Starting and then withdrawing treatment is a very difficult thing to do, and I think some physicians would simply continue treatment due to inertia and, unfortunately, the ease of throwing medications and procedures at a problem as opposed to having a very long and difficult conversation. By initiating treatment you may introduce them back into the system where they would have a complicated medical course costing not just time and money, but the emotional well-being of the family who had been taking care of them. Circumstances permitting, it might be a good idea to hold a candid talk on initiating treatment in the first place. This is, of course, not the easiest thing to do while under the constraints of a busy ED and facing a critically ill patient, but it’s a worthwhile task nonetheless.
ReplyDeleteBryce brings up the costs of (1) inertia and (2) the family's emotional well-being. We will certainly get to the inertia question in class.
ReplyDeleteThe physical cost to the patient can be tremendous. Life-saving treatment implies that there is a serious, life-threatening condition. To fix such a condition quickly, the treatment might have to be more aggressive than it would be in a non-emergent situation. This could then cause further damage (for example, broken ribs after good CPR). The fact that it was a life-threatening condition then allows justification for the treatment-induced damage; that is, most would agree that it's better to have broken ribs than to be dead.
ReplyDeleteGreat: Physical damage is a good example of how there's more than monetary costs to the patient.
ReplyDeleteI think that we also need to consider the cost of not starting life-sustaining treatment - especially in an emergency situation. Often it is now or never, and the cost of withholding treatment may not be immediately apparent. Because time is such a factor in the ED, the concept of buying time (as mentioned in the challenge statement) cannot be overstated.
ReplyDeleteSo the cost of NOT starting treatment could be loss of life (at the individual level) or lost productivity (at the societal level). Which patients do we see this argument being made in most often?
ReplyDeleteSo.. Costs aside, I think the idea that "there is no difference between withholding and withdrawing treatment" is not POSSIBLY true in all cases.
ReplyDeleteTake CPR for instance.
Now, regarding costs... my opinion is this:
Life is cheap.
We have plenty of people.
And we can always make more.
HOWEVER.... we help people anyway.
I for one, and I think society in general, think a person's health and life MEAN more than they are WORTH. So running cost vs benefit almost always comes up as NOT WORTH IT. Making it meaningless.
But that said, I think we weigh benefit a lot heavier than cost.. and rightfully so.
Of course, if there is no benefit to be had, we should certainly spare ourselves the cost.
thank you.
Are you suggesting that cost/benefit analysis may not actually be humane when we are considering life saving measures?
ReplyDeleteMy initial thought was similar to Bryce's - although ethically there is no distinction between withholding and withdrawing treatment, there is definitely a social component to those decisions that are very different. It is much harder to decide to withdraw treatment after it's been started, then to never start it in the first place. The emotional burden is potentially transferred from the doctor to the patient if treatment is started then removed later, as the family usually has to come to the decision to stop the life-sustaining treatment. This is a huge burden when they are already dealing a tragic situation. If, however, treatment is not started in the first place the emotional burden stays with the provider who is probably better equipped to deal with it than the family.
ReplyDeleteSecondly, context should be taken into account. If an elderly patient with late stage Alzheimer's comes in (as in our reading), should we really spend the resources to sustain his/her life further? Additionally, what cost does this impose on his/her family as well? There seems to be a sentiment in our country that it is not okay to die - that somehow the medical system has failed if that happens. This in turn causes financial stress for patients and their families. When we take context into account we consider a person's quality of death and honor their life by respecting the idea of a nice departure from this life. If the cost is high, the gain is low (terminal condition) we should put quality of death on our radar and strongly consider withholding treatment.
I don't know if I mean humane... just not... Linear.
ReplyDeleteIN a traditional Cost/Benefit analysis you would weigh both sides relatively evenly, and chose to act or not to act based on the comparison. It implies a quantitative measure of things.
In the ER, I think maybe there is a correction factor... a BIG correction factor, in favor of action. Obviously at SOME point, the we decide that the 'cost' outweighs the 'benefit'... but in all likelihood, if we analyzed it objectively, that point had come and gone long before.
Adding to the theme of fiscal cost in the context of life saving treatment, the people in this country are pretty much immune to the enormous medical costs that life saving treatment can incur. We don't have a resource-limited medical system (this is a generalization as rural communities have fewer resources), and that influences the way that we administer life saving treatment. It seems like we do make last ditch efforts to save people that we know aren't going to make it and many of these interventions like ER use and ICU stays are costly. Elsewhere in the world, where the luxury of lifesaving treatment is rationed, it is more likely that care will be rationed out to "good investments"- people who are going to survive with minimal morbidity. I'm not saying that our approach is wrong, but we have an attitude of excess that might not be serving the most amount of people the most effectively.
ReplyDeleteThere are medical, ethical, sociatal and legal costs that are associated with starting life-saving treatment in the ER. Medically the patient has great cost if treatment is not started. The sociatal costs include both monetary and psychological costs. The psychological costs involve how people perceive the hospital and doctors. Legal costs could be invovled if lawsuits or hearings are necessary. Ethical costs are also a consideration; the four box method would work well here. In regards to which one wins, I think that going back to our four basic ideas of autonomy, benificience, do no harm and justice need to be weighted and then can be used in each circumstance.
ReplyDeleteI agree with Russell on the point that our country seems to have a real problem with death, and dying as a natural part of the life cycle. My mom is an ER nurse, and she always feels bad when an elderly, frail, dying patient is brought in from hospice/nursing home to have tubes and needles shoved in all over. In this case, I would say that palliative care would be justified. This requires preparing the patient and family for events that will happen at the end of life (POLST form, etc.) and also the physician being open/honest about realistic expectations of outcomes (are there going to be true benefits to initiating life sustaining treatments?) This comes back to Cameron's cost/benefit analysis (but who is to say whether this treatment would be "worth it?")
ReplyDeleteSome of the costs are borne out before the patient makes it to the ED door. Does the primary provider have time to have the end of life discussion? Does the family have time to come to the doctor visits to have the same discussions? How about the emotional costs for a family to have these discussion? Doesn't mean it shouldn't happen, but there is a reason why all of this is addressed prior to the hospital setting.
ReplyDeletePeople become immune to the relative financial costs of health care because most of the time they are not asked to bear the total cost. While the number of uninsured and underinsured is growing, people often don't pay attention to the cost of the care. When they are sick they want access and they want it now.
I agree with David's comment about the general public being insulated from the actual cost of health care. Some argue that one of the main reasons the cost of health care or rather health insurance is so astronomical is b/c people aren't cost conscious. they don't really shop around and pick the plan that offers the best deal....this gives insurance companies no incentive to compete in a typical capitalistic manner. To add to this insulated mindset is the fact that most insured people have insurance is employee based insurance where you just rely on the employer to pay the monthly premium and don't really question how much it's costing (and often times don't even care).
ReplyDeleteIn a continuation of the DNR statements - one of the costs of starting life-sustaining treatment is the loss of autonomy. Patients have different needs & concerns regarding their treatment & in an emergency situation, the ER may not be able to comply immediately with the patient's wishes.
ReplyDeleteIn addition - I agree that life does outweigh physical, life-sustaining treatment is financially costly & may become a burden to the patients at a later date.
Ideally withholding treatment would not be influenced by an undertone of financial costs to the system at large. However, some families begin to feel the cost burden of treatment if the pt has a history of needing it. Most of the time our financial counselors work very well at alleviating the burden of care but certain cultural beliefs may prevent some populations from accepting the help. This in turn pressures then into making a decision, if the surrogate, or talking the pt down a road that is not advisable by the physician.
ReplyDelete