My favorite post in this week’s Grand Rounds was from Amy Berman, writing at Health AGEnda (the John A. Hartford Foundation blog). Amy’s article is particularly compelling because it’s so personal, as she shares the details of her recent diagnosis with stage IV inflammatory breast cancer. But it’s also an excellent insight into the broader implications of how we view medical interventions, especially in cases of terminal illnesses and treatment for people who are nearing the end of their lives.
Amy’s experience with a doctor who proposed aggressive treatment (chemo, radiation, mastectomy, more chemo) for terminal cancer was met with her own knowledge (as a nurse) of how such treatment would likely dramatically lessen the quality of her remaining life, even if it did extend her remaining time somewhat (and even that might not be the case). And she also had another opinion from an oncologist who recommended a much less invasive protocol of medications to slow the progression of the disease while still retaining quality of life. But she points out that many people (especially older individuals who may be struggling under the weight of numerous ailments) might end up being railroaded into aggressive treatment scenarios that result in diminished quality of life, simply because our system focuses so heavily on prolonging life at all costs.
Although the most obvious cost in the more aggressive treatment program Amy described is the loss of quality of life, the health care reform debate over the last few years has raised the issue of financial cost to the forefront of the discussion. I don’t know the specific details about the medications recommended by the oncologist who proposed the less aggressive treatment plan, but it’s likely that the total cost of care would be far less than the cost of chemo, radiation, a double mastectomy, and more chemo. And as Amy points out, the first course of action will allow her to maximize the quality of her remaining life, which was the most important aspect for her.
Deciding on a treatment plan in the sort of scenario Amy describes is an intensely personal decision, and of course not all patients with the same diagnosis would have the same objectives. That’s why it’s so important that doctor’s listen first and foremost to their patients’ desires, rather than relying on one-size-fits-all protocols.
But Amy’s story is particularly important when we look at end-of-life scenarios, where doctors and hospitals will often take the approach of sustaining life at all costs, simply because it’s what we’re used to. I’m not advocating the rationing of health care in people who are terminally ill; patients should be given choices regardless of their prognosis. But honest discussions about end-of-life care and a genuine focus on quality of life might help to not only make life better for patients facing terminal illnesses, they could also result in lower health care costs.