If Healthcare is a God-given Right, How Can We Possibly Consider Rationing It?

 

It was Thursday night and I was just getting ready to go to bed. It was 11 pm and I turned my phone on to see if I had missed any messages. I wasn’t on call for emergencies so I had my phone set to vibrate. When I looked at the phone I saw that I missed a message at 9:11. Actually no one was on call for neurosurgical emergencies that particular evening.

So, when David Osgood arrived at the ER with an abnormal brain MRI scan which was done as an outpatient earlier that day, Kelly the ER nursing director sent out a text to see if any of the staff neurosurgeons were available to take care of him. I tried texting her back but got no answer so I called the ER directly and spoke with Dr. Feusner who was on duty. She told me that arrangements had been made to transfer David to another hospital but that he was still there at Mease.

I told her it wasn’t necessary to transfer David and that I would be available to see him first thing in the morning. So she cancelled the transfer and arranged to have him admitted to Mease Hospital.

David was 67 years of age, married with three children, two daughters and a son. He had recently developed a facial droop on the right side of his face and also was having some difficulty speaking. It wasn’t that he couldn’t speak; it was just that he had trouble getting some of his words out. He also had weakness of his right arm which began at the same time as his speech problem. Initially his doctor thought he had a stroke, but when the MRI scan was performed it was clear his symptoms were not due to a lack of blood flow to his brain but a tumor located right in the center of his frontal speech area, on the left side of his brain. Dr. Feusner told me David had a tumor; I just didn’t know the tumor likely was inoperable until I walked into David’s room the next morning.

As I entered his room, David was lying in bed and his wife Marjorie was at his side. They only had a vague idea of what the MRI showed and were certainly hopeful that despite what was in his brain, there would be a treatment for it, even if it required surgery. I picked up the MRI folder and turned to the window as I began pulling out the films one by one, holding them up to the sunlight to see what kind of tumor David had and where it was located. I too, was hopeful that there was something I could do for David, but as I looked at the scans, my heart sank. Because of where the tumor was located, surgery would almost certainly worsen David’s problem speaking, or aphasia. In other words, he would be able to understand what was said and perhaps even know in his mind what he wanted to say but wouldn’t be able to verbalize a single word.

And to make matters worse, this tumor was most likely a malignant astrocytoma. Given this diagnosis and the inability to aggressively remove the tumor made it likely that David would have 6, perhaps 12 months to live.

Knowing all this, I now had to turn away from the window and face David and Marjorie. Times like this are probably the second most difficult conversations I will have with a patient and their family. I have to be honest, yet at the same time I must give the patient hope. And as I stood there, during the first few seconds while I contemplated what I was about to say, I thought how can I possibly project a hopeful outlook?

That’s the thing about these conversations…patients listen to what I say but more than anything they study my facial expressions and how I deliver the message to determine if there is something I am not saying.

I explained to them what kind of tumor I thought it was, and the fact that even with an aggressive surgical resection, tentacles of the tumor would likely be left behind. The problem was, I told them, that because of where the tumor was located, it might not be possible to safely remove any of the tumor. I asked if I could have some more time to study the films further and that I would return later in the day to speak with them again. ‘Of course’, they said in unison. So I took the MRI scan and walked back to my office.

I told Chad my PA about David and what his MRI scan showed and asked what he thought I should do. I knew I was the only one that could make that call; he merely shrugged his shoulders and said, ‘well you could debulk it ‘, although he and I knew too well the possible implications of that.

I returned to David’s room later that afternoon to speak with him and Marjorie although at this point I still had not completely decided what I would do. In part, this is because the phrase’ ‘Do no harm’ is more than just a cliché to me. By this time his children had arrived and surrounded his bed. I began by repeating most of what I said earlier in the day since David’s children had not been there. At one point David asked, ‘How much time do I have?’, only because of his aphasia it came out more like, ‘How much light is there?’ Not wanting to take away all hope and yet at that moment realizing what I needed to do, I told him if we did nothing he might have 6 months. If I operated and removed as much of the tumor as I could safely, inserted some chemotherapy wafers in the brain and post-operatively he received radiation and additional chemotherapy, he might have 12 – 18 months or possibly longer. Through the tears he and his daughters were shedding, he said ‘OK, do it’!

‘Why are you cast down, O my soul,

and why are you disquieted within me?

Hope in God; for I shall again praise him,

my help and my God.

Psalm 43:5

Immediately following surgery, David’s ability to speak had worsened somewhat although it slowly improved during his stay in the hospital and when Francy, my nurse saw him for an incision check 10 days later his speech was back to where it was when I first met him.

Only time will tell whether I appreciably lengthened David’s life here on earth. Which brings me to a thought? With all the concern over curbing the rising cost of medical care, if we know that, statistically, a patient’s survival from a malignant astrocytoma will not be long, do we withhold treatment? Personally I think this would be wrong…dangerous…and evil. Because then we would be playing God, essentially determining the worth of a human life. It is one thing for a patient or the family, if the patient is unable to make that decision, to decide enough is enough, but the only other one to make that decision should be God, not us.

As I have pointed out before, extending one’s life even 3 months can be a miracle if allows a human hurt to healed or gives family the opportunity to say goodbye, at least for now.

Comments

[Krissy King]

So enlightening! Where can we post this for all to see?

[Hal Colbassani, MD]

Krissy,
Thanks for your encouragement. You can easily post this to your facebook wall, or feel free to pass it on to your friends via email as well.
Thanks again
Hal