Dr Parks at Buckeye Surgeon discusses his recent encounter with a functional 92 year old with metastatic breast cancer (lung and liver) who made a decision to proceed with chemotherapy. Of course, she didn't look ninety. But she wanted a little more time to see two of her grandchildren get married.
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile? What if she was a functional 100 year old? Should she be offered treatment? How about a functional 110 year old? Should she be offered treatment?
When the Medicare National Bank (MNB) was established in the 1960's nobody could have predicted that 92 year olds would be getting chemotherapy and surgical ports for metastatic breast cancer. Medicare was not set up to provide for that care. The MNB was set up to keep people from dying, not to keep them from dying.
Exactly what rational system of rationing are we using here? Is it rational not to have one at all? Mrs Happy's great grandmother found a hard protruding bump in her abdomen several years ago. She was 90 years old. She was told it was probably a hernia. She was a vibrant functional living at home 90 year old. Two months later she presented to the hospital with shortness of breath and a bloody pleural effusions. Confirmed undifferentiated carcinoma. A month after that, the day after Christmas, she was dead.
She didn't get chemo. She went home, to enjoy the last remaining months of her life around friends and family. She died peacefully at her home, under hospice care. Could she have undergone a biopsy, surgery, chemo and port? Of course. She could have had it all. She could have said she was prepared for it all: chemo, infections, immunosuppression, blood clots, pneumonias, sepsis, fevers, chills, sweats, bowel obstructions, vomiting, nausea, pain, delirium, anorexia, severe weight loss. She could have been prepared for it all. She could have done all that.
Why? Because she was a vibrant, functional living at home 90 year old with great grand children who hadn't yet been married. But she didn't. Because doing so would mean giving up the last remaining months of her life in strange places with strange people, strange noises, strange smells, and loosing all dignity as the struggle to survive consumes your every moment.
I saw great grandma Sylvia up until the day before she died. She never thought she was going to die. That kept her alive until Christmas, which I think is all she really wanted in the first place. Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us. The longer we pretend that treating metastatic breast cancer in 92 year olds with chemo and a port is quality medicine, the less relevant we become as a profession.