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Assuaging Grief with Expensive Medical Technology

January 7, 2014
By

The case of Jahi McMath is incredibly sad. She is the 13-year-old girl in Oakland, CA who had tonsil/adenoid surgery to treat sleep apnea. Her throat began bleeding profusely hours after the surgery. This ultimately led to her being placed on a ventilator, experiencing period of low oxygen in her blood and eventually brain swelling, and later being declared brain dead. Best I can piece together from news stories, three doctors, including a doctor from an academic center not affiliated with the Oakland hospital, agree that she is brain dead.

And in California, brain dead is one of the criteria that determines death. Therefore, Jahi is legally dead. This is the same criteria used in most other states.

This case has been in the news a lot, because the family sued the hospital to keep her on the ventilator. The doctors and hospital wanted to remove the ventilator, but a judge has ruled to keep her on it, at least until Jan 7th. The family had tried to transfer her to a long-term care facility, but no local facility would take her. The latest plan is to transfer her home.

We can all sympathize with the pain of losing a child. This pain must be compounded by the fact that a very rare – but known – complication of an elective surgery was the mechanism that killed her. Her parents may blame themselves for the decision to go with the surgical approach, thus making tremendous grief even worse.

As sad as this case is, it is also a disconcerting demonstration of how unprepared our country is to tackle inappropriate high-cost healthcare. If a judge doesn’t have the courage to remove expensive medical technologies from a legally dead person, what will we be able to accomplish if we ever begin to address situations that are grayer?

Will we ever be able to tell a patient with chronic back pain and several failed surgical attempts that no more procedures will be offered? What about $100,000 chemotherapy regimens for patients with metastatic cancer and no hope for a cure (and especially if the patient had already had little improvement from previous treatment attempts)?

The Institute of Medicine generated a widely-quoted figure that 30% of all American healthcare expenses are unnecessary. While I mostly believe this number is true, the plainness of the number implies that reducing unnecessary care will be easy. Just stop doctors from ordering gallbladder scans for patients with no gallbladders, and surgically replacing joints with no disease, right?

The Oakland case shows that reducing U.S. healthcare waste will be extremely difficult. Other cultures are much more comfortable at accepting the inevitability of death. Even in this extreme situation, healing can progress without ICUs and mechanical ventilators as life moves on for the living. Other cultures accomplish this through extensive family involvement in the care of their dying, rituals and remembrances – both public and private, and religious observations such as Dia de Los Muertos in Latin America. Presence of loved ones and shared caring supplant expectations of technological miracles.

Many Americans have lost this ability to accept death as a part of life. We assuage our grief of the dying and dead by the mis-application of expensive medical technology whose utility is often somewhere between marginally useful and absolutely futile.

The irony of this approach, especially in the Jahi McMath case, is that the money to pay for this technology has to come from somewhere. In the case of private insurance (and no news report I could find stated the coverage in this case), cases like this rob wages and jobs from working-age Americans now. In the case of public healthcare coverage, cases like this are worsening the lives of our children in the future. By artificially keeping the organs pumping in a dead child, the children of tomorrow will have more debt to pay.

Will we ever develop the national courage to stop this madness?

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2 Responses to Assuaging Grief with Expensive Medical Technology

  1. Terri W. on January 8, 2014 at 11:26 am

    So why doesn’t your employer, JPS, use this definition of “dead” in the case of Marlise Munoz? Are Texas laws different than most states in how to define dead? Who is paying for this dead woman’s care?

    From a recent Star-Telegram article on the subject:

    Three Texas experts, including two who helped draft the 1999 law, told The Associated Press last week that it doesn’t apply in the Muñoz case. “This patient is neither terminally nor irreversibly ill,” said Dr. Robert Fine, clinical director of the office of clinical ethics and palliative care for Baylor Health Care System. “Under Texas law, this patient is legally dead.”

    http://www.star-telegram.com/2014/01/05/5461613/husband-says-texas-law-shouldnt.html

    • Richard Young MD on January 9, 2014 at 9:56 pm

      Terri,

      I wondered if someone would bring this up.

      My first picky point is that JPS is not my employer. There are a few exceptions, but generally speaking hospitals in Texas cannot hire physicians directly. I work for a separate physician’s group.

      Here is the actual wording from the Texas Advance Directives Act:

      Sec. 166.049. PREGNANT PATIENTS. A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient.

      I have heard reasonable people on both sides of this issue agree with your position and the position JPS has taken. I think we can all agree that this is an extremely sad and fortunately rare situation where there are no easy answers. I don’t mean to speak for JPS, but I think it’s safe to say that its legal department has taken the position that the spirit, if not the letter, of the law is that life support continue if there is a pregnancy.

      Hospitals and doctors must suppress their personal views sometimes to do their best to provide hospital services or practice medicine in a manner consistent with the will of the people of Texas as expressed through its elected officials in the legislature. I can assure you that the decision makers at JPS are good people of high integrity, and they are making difficult decisions in a difficult situation. Allow me to say that I am glad that I have nothing to do with this case and really know nothing beyond what has been in the general news.

      Contrast the JPS situation with the Jahi McMath situation where are no complicating factors anything like a pregnancy, just a legally dead person.

      Thanks for the question.

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