Tuesday, May 4, 2010

Dying by the Numbers

One of the hospitals where I used to work had the daily census listed on their internal website. While I always appreciated the information, I was never quite sure how to use it. If the census was low, was I supposed to admit more people to fill up the place? If it was high, should I have been tossing more people out? Inevitably, I just went about my job admitting those who needed to stay and discharging those who didn’t. Somehow it all balanced out.

This is why I was so intrigued to find out that one local hospital not only posts census data, but does so with budget targets as well. The addition of the budget targets adds a slight element of creepiness to the statistic…you get the sense that if you don’t admit enough patients and the budget targets aren’t met, your job, and the jobs of those nurses and other support staff who depend upon the revenues generated by hospital admissions, may be on the line. While I have honestly never heard of any hospital getting rid of a doctor because they don’t admit enough patients, but it’s a changing world out there. Twenty years ago the idea of physicians as hospital employees, working for set wages and answering to non-medical professionals, was anathema. Now it’s a relatively common scenario.

The data is also posted for the hospice operated by the hospital, and it’s here that the creepiness level reaches new heights. As you may know, hospice services provide comprehensive comfort care for people in the last stages of terminal illness. Rather than focusing on the prolongation of life at any cost or the fruitless search for a cure, hospice efforts focus on allowing the patient to die with dignity, free of pain, and maximizing the quality of life to the last possible moment. I’ve seen hospice physicians and nurses do amazing things, applying their ideals to scenarios I would have thought impossible even a decade ago.

While many people have heard of hospice helping patients with chronic diseases like cancer, it’s another case that really stays in my mind. About a year and a half ago I saw an elderly man with a leaking abdominal aortic aneurysm. An abdominal aortic aneurysm is a complex medical problem. (It’s also really hard to spell or to say three times quickly, which is why we write it as an “AAA” and call it a “Triple A.”) The aorta is the largest artery in the body. It comes directly off the heart and has branches within the chest that go up towards the head (the carotids) and to both arms (the subclavians). The main body of the vessel then extends down into the abdominal cavity where it gives rise to blood vessels that supply the abdominal organs, and the kidneys, and then branches off to form the iliac arteries that bring blood to the legs. An AAA occurs when the wall of the aorta weakens and expands, eventually becoming so this that it ruptures and blood leaks out from the tear. Unless repaired, the patient inevitably dies from internal bleeding. Depending on the site of the rupture and the volume of the hemorrhage, death may be immediate or prolonged. But the patient still dies.

The patient I was seeing had actually come to the hospital with abdominal pain, and in the process of workup a CT scan of the abdomen showed a slowly leaking aortic aneurysm. This would have been a very complex repair, as the aneurysm not only involved the aorta, but also portions of the other vessels that come off the central artery. In many cases, an AAA can be repaired; the damaged portion of the vessel is removed and replaced with an artificial graft. But when other vessels are involved, surgery becomes a nearly impossible task.

Clinical decisions regarding surgery are not made solely on the basis of the acute medical problem. When surgery is contemplated, a whole host of factors come into play. These include the patient’s overall health and nutritional status, the presence of other acute or chronic medical problems, and their current quality of life. And it became clear that this patient, who already had significant heart and lung disease, was going to die no matter what.

Ten years ago, before our local hospice movement had really gained speed, one of two things would have happened. The surgeon would have convinced the family, or the family would have convinced the surgeon (you’d be surprised how often the latter version occurs) to give life-saving surgery a try. The patient would have said his last goodbyes in the pre-op area, and his last visions would have been of the harsh glow of the OR lights. Alternatively, he would have been admitted to the hospital and stuck in a corner room far from the nurses’ station, to be warehoused for a few days as an expectant death. Neither of these is a good option.

Enter hospice. With hospice, we were able to get the patient home. He would receive round-the-clock intravenous pain management therapy that he controlled to his own level of comfort. His family would have time to gather and say goodbyes in his own home. It was agreed that no CPR would be done so as not to prolong any pain, and that he would not suffer the indignity of a futile effort at resuscitation (while very exciting by television standards, cardiopulmonary resuscitation in real life is a messy, dehumanizing business). And the entire effort was done with care, compassion, and attention to the needs of the patient rather than the needs of his disease. I hope that if I’m in that kind of scenario, someone will be as kind and gracious to me.

(Incidentally, if I have to go…which is a prospect I’m decidedly not enthused about…I’ve decided I want to go one of two ways. I either want to go very slowly after a long and healthy life, spending time with the people I love, traveling the world either accepting tear-laden apologies or extracting revenge from everyone who has ever wronged me in this life. To be frank, the fact that I’m pushing 50 with all my own hair and teeth and a distinct lack of a beer gut already has me on the revenge track with a few people.

If I am fated to die young, however, I want to go quickly and unexpectedly, with no chance to contemplate what is happening to me. I also want it to be a really good story. So I don’t want to die in a plane crash where I have 36,000 feet of descent to think about it, nor in some kind of routine motor vehicle accident. Getting knocked off by a flaming beer truck which crossing the road to see the Cole Slaw Wrestling during Bike Week? Now that’s a real death, a tale for the ages.

Oh, and one other thing I might say about hospice. Our local hospice is located across the parking lot from one of our hospital campuses. The food in their cafĂ© is really very good, stunningly so given that it’s a hospital-based institution. The Lords of Dark Humor say that’s because at hospice, every meal can be your last. Which is why I’m not eating there. I do, however, occasionally join my colleagues in walking to lunch at hospice to get some precious moments of sun time. This leaves the ED uncovered by a physician for a few minutes. That’s why before we go, we leave a note for the nurses describing emergency procedures. The note reads as follows:

1. Do CPR
2. Give epinephrine (adrenaline)
3. Do CPR.
4. Pronounce.

Which is actually not a joke, but pretty much a statement of fact.)

The idea of dignity of the individual is such a core value to the hospice ideal that when my friend showed me the website, I was stunned to find the following information (changed slightly for anonymity):

Hospice of the Cities

12 AM Census: 572
Budget Target: 595

I recognize that there are good and sound fiscal reasons for establishing budget targets, and that any fiscal plan for an organization depends on a projection of revenues. In the case of a hospital, these revenues are garnered through patient care. There is nothing wrong with acknowledging this. But just as medicine is both a science and an art (and I would personally argue much more the latter), the management of financial data is as well. There are both right and wrong ways to present fiscal information for public consumption. I’m surely not a marketing person, but if the above data strikes an informed consumer like me as callous and insensitive, I can only wonder what it looks like to a lay person.

So what does a loyal employee do to help the institution? Clearly, not enough people are dying, or not dying slowly enough to admit to the hospice. The numbers need to come up. But going out to whack people with your car is not a solution. The folks you hit will either die on scene or undergo a slow and prolonged recovery, and in either case they don’t qualify for hospice care. Exposing your neighbors to excessive radiation may raise the numbers of patients with terminal cancer, but it’s also sure to draw the attention of the Federal Government. That’s never a good thing, especially as they need to fill Guantanamo Bay with someone nowadays.

To the extent that the message of the merits of hospice should further penetrate the community, the numbers may serve as a useful reminder. And there is no doubt whatsoever that the idea of managing death as skillfully as managing life needs to reach into the hearts and minds of those physicians advising patients and families in the last stages of illness. These measures are sure to raise both referral rates and the quality of end-of-life care.

But setting up the dying as a very public budgeting target? That’s an idea that needs to expire quickly, without any comfort or dignity at all.

1 comment:

  1. Unfortunately, I've seen similar behaviors in ambulance services. They had budgeted transport numbers, as well as target ALS transports. If we were below budget on ALS calls, the word would come out for IV's for everyone!