As I get ready to go home, my nurse hands me a note: “See Mrs. Jones in room 311 Today.” Although I have already been to the hospital, it is my weekend on call, so checking on Mrs. Jones is my duty.
I call the hospital, and a nurse fills me in: " Eighty-eight-year -old lad with Alzheimer’s transferred to the hospital from the nursing home with a fever and probable blood infection." She pauses. The situation didn’t sound serious enough for a gastroenterologist like me to have been called. “She’s got a distended stomach; the internist had to put down a tube to relieve the pressure,” the nurse added, sensing my puzzlement. “That must be it.”
I inform her that I will be in to see the patient as soon as I finish in the office. At the hospital an hour later I look at the patient’s X-rays before seeing her. She has a distended stomach and the tube is properly positioned. When I reach the floor the nurse greets me.
“She’s not doing very well. I don’t think she’s going to make it.” The nurse seems less concerned than I would expect. She notices my perplexed expression. “You see, Doctor, when I spoke to you I forgot to mention that she’s a DNR [Do Not Resuscitate]. Came that way from the nursing home.” So that was it: probably the patient’s family, with the advice of the doctor at the nursing home, had made that decision rather than subject her to extensive, expensive and ultimately fruitless measures. But our health-care system won’t allow this. And I’ve allowed myself to be made a pawn in the game.
I have seen this happen time and time again: a human being reaches the end of his or her life, but the family, or the nursing home, doesn’t want the person to die there. Too much trouble; there might be an investigation. So they ship the poor soul-often comatose and “pretzeled,” as medical staff sometimes say, in the fetal position-to the hospital. The hospital calls in a specialist (like me) to protect itself from any possible malpractice charges. The specialist in turn orders all sorts of expensive tests, procedures, maybe even surgery. All of which gets billed to Medicaid, i.e., the taxpayers. It’s a horror for the patient, a horror for the family and it’s costing us all a fortune, money that could be better spent on lives that can be saved.
“We’ve got to cover our asses, or they’ll sue us or worse. The family wants everything done.” We repeat this mantra of self-serving paranoia as we put our patients through paces that frequently serve only our own interests. I understand that if not for patients such as these many hospitals would be mostly empty. I hear it every day but usually ignore the absurdity. I have become inured to a health-care system gone crazy because I have to function within it. I realize that if DNR meant “Do Not Reimburse” instead of “Do Not Resuscitate” far fewer of the terminally and hopelessly ill would receive pointless treatment.
If I were to suggest in this particular case that nothing be done to try to save this unfortunate woman, her doctor would probably call someone else, never call me again and consider me a troublemaker. My specialty in particular has a reputation, largely earned, for maximizing the dollar value of every patient while internists and family doctors, who work the longest hours, receive far less compensation than their specialist and surgical colleagues. Who was I to tell him that further tests were a waste of money? But if not me, then who?
The nurse and I pass a half dozen rooms. The faces have no names and blur in my mind as we breeze by. Have I come to see them as human loaves of bread in the health-care supermarket? The anonymity of life in a nation of mass convenience seems even more appalling in these very human terms. I cannot look away. I slow down and examine the faces. Some are asleep; all have slipped closer to the end. Each is attached to at least one piece of technology, modern medicine’s bulwark against death, replacing prayer, kindness and compassion. In the name of what? Money?
Some of them will die alone, hands unheld, faces unstroked, sanitized. Why do we accept this expensive, inhuman set of circumstances? In coming so far it seems we have left some very important things behind.
The nurse reaches the patient’s room before me. I have stopped walking. The nurse walks slowly from the room. “She’s already dead, Doctor. Sorry.” I also am sorry. Faxes, car phones, beepers, scanners, specialists skilled in the latest technology are wonderful. They save time and lives. And we can bill the government for them because they are easier to quantify than judgment, compassion and kindness.
As I drive home I imagine I am standing on a podium before the entire nation. My speech contains the answers to all the problems that face health care in America. In my Utopia doctors will make enough money but not too much, striving always for what is best for their patients while keeping a vigilant eye on waste. The public will not only take on greater responsibility for their own health but will also come to understand the complexity and limitations of medical technology. The audience roars its approval for this sweeping vision.
I pull the car to the side of the road, next to a small park. It is a beautiful day, and for the moment, I’ve finished being a doctor. There’s a bench near an old maple tree. As I step out of the car a warm breeze strokes my cheek and a tear makes its way across 40 years of hopes and dreams. I sit on the bench to enjoy the moment.
