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Rationing at the bedside: Is it ever acceptable?
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I participated in an interesting discussion yesterday with some colleagues from other institutions about a patient with a serious, though not strictly terminal, diagnosis. The treatment the patient required during an acute exacerbation was extraordinarily expensive, costing several tens of thousands of dollars a day. As time went on during a prolonged hospitalization, it was clear eventually that the care being provided was futile, whether by strict definition or at least by instinct, because of a variety of intervening problems that had arisen.
The patient was transitioned to comfort care and expired. This story in general terms is not an uncommon one, and unfortunately replays itself all the time in other patients we care for, young and old, with many different diseases. What was a little different about this discussion, though, was the extraordinary price tag — and the current national discussion about health care reform. Some argued that the providers in this case should have recognized earlier that the diminishing returns being realized by the patient did not justify the immense cost of the treatment. References were made to the “costs of care” — not to the patient, but rather to the hospital, to other patients, to society at large. Some mentioned that it was especially important to be mindful of these considerations because, they believed, we are being directed to think about the costs of care through the national discussion around health care reform.
I was troubled. To me, this was beginning to sound suspiciously like bedside rationing. And I’m not aware that the current health insurance reform bills include anything that directs physicians to do this. As many of you who read my blogs and columns know, I am a bit of a skeptic when it comes to expensive new treatments with apparently very modest clinical benefit. I worry about the impact of these treatments on quality of life, symptoms, or the financial burden of a patient or a family. But I also like to think that I advocate forcefully for my patients to receive whatever I ultimately believe to be personally tailored, state-of-the-art care — regardless of how expensive it is (so long as the financial impact on my patient is tolerable, by his or her standards) or what the implications are for the health system.
Again, in my mind I don’t promote futile care, or over-testing, or overtreatment (I hope), but I do acknowledge that good care is expensive. And I think that if I rationed at the bedside, I would be introducing a conflict of interest that would raise questions about to whom my ultimate loyalty is directed. But what do you think? Do you think that we should be considering societal cost considerations when we’re deciding what care to deliver to our patients? If so, when? What constitutes futility, and should this definition change? I’ll be interested to hear your opinions.
