End of Life

September 23, 2009


Some things have become clear in the health care conversation. One is that providing insurance for everyone is going to cost money and that money is going to have to come from somewhere. Two is that people who are currently insured do not want to lose the coverage that they have and that with a change in the system there is some likelihood that something will change for everyone involved. Three is that no one really knows what drives health care costs and that if there is not to be overt rationing of resources then our behavior has to be changed in some way regardless of insurance, if we are going to reduce or manage the amount and proportion of GNP (or whatever) our society spends on health care. Each and maybe all of these realities are going to be resisted by someone. We have more or less adjusted to the changes that brought about ‘managed care’ and those changes, while not fun, appear to have slowed the rate of growth in health care costs, and we can all adapt to any changes that come out of the current reform.

My instinct is that it is the third of these issues (cost control) that generates the most difficulties for us because it is so hard to know exactly what is driving costs in the first place. Is it doctor’s insurance in a litigious society? The cost of development of drugs and ever-more-accurate, ever-more-expensive diagnostic tools? (Hands up everyone who has ever had and MRI for a headache.) The existence of good insurance with little or no ‘co payments’? Insurance Company shareholders insisting on profits? Or is it just a plain old combination of these and a host of other factors all being driven by our fundamental fear of death? Apparently 30 percent of Medicare costs relate to the last six months of life. I can think of numerous situations in the past thirty years where medical costs near the end of life could have been reduced and treatment in the face of death made a great deal more humane for everyone (patients, families, nurses and doctors) if only there had been some serious conversation about the patient’s wishes while she or he were able to have those conversations. My attorney always addresses the need for a medical power of attorney whenever I revise my will (which is good), but that doesn’t really lead to lead to clarity. I can say quite clearly that I want aggressive and expensive treatments to have a more than 70% likelihood of being effective in restoring me to some kind of enjoyable quality of life, and I want the people who know and love me to judge what that would be for me. I do not want to say that there is no point or worth in a life in which a person is severely handicapped or incapacitated. I do not want to make those kinds of decisions for others and I certainly don’t want any laws that could lead to pressure on patients to do anything other than affirm life (even though I suspect that some things that pass for affirmation-of-life are really a far of death that is part and parcel of an already-happened spiritual death.)
Years ago, when it was still common to be in the hospital for eight weeks following a hysterectomy, for example, I put on a well attended Sunday School class on ‘the hospital experience’. A chaplain talked about end of life choices and planning. Afterwards a doctor, who acknowledged that he had gone into reconstructive surgery in part because of his abhorrence of death, asked some pointed questions. The chaplain’s response was affirming of the concerns and work of that doctor. He said “When I go to the doctor, I’m not really looking to speak with someone who is comfortable with death. I want someone who is gong to make me better.” Well said. The doctor’s office is not the place for conversations about choices at the end of life to happen any more than meeting with a bereaved family is the time to teach what makes for good liturgical choices about funerals. But those conversations need to happen somewhere and regularly if there is to be any hope of really controlling health care costs through changed behavior. We don’t want to reduce or be cavalier in any way about the importance of the gift of life. At the same time we don’t need to be turning some technical measure of life (breathing, heartbeat, brain activity) into an idol. We can put on classes and create safe spaces for conversation, but what will make us want or need to attend?