Medicine Is Not About Saving Every Patient
A harsh truth coming to the forefront because of the coronavirus.
During the last few months, how many of you have with horror seen news stories about Intensive Care Units (ICUs) having to prioritize CoViD-19 patients in need of respirator support? The actual headlines look more like “Older patients with coronavirus are not being treated in [insert hospital/country here]”, which sounds even more terrifying. When referring to Italy for example, this is indeed a troubling development which indicates that many healthcare systems have been inadequately prepared for such a wave of critically ill patients.
It is a scenario every hospital, city and country in the world works day and night to avoid right now, because we all know what has happened to those healthcare systems that have been overcome by the flow of coronavirus patients: Thousands upon thousands of deaths, with an extremely painful period of exponential increase in fatalities, before a total lockdown manages to stop the uncontrolled spread of the virus.
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Inhuman practices against the elderly?
Even in the above extreme scenario however, the notion that people above a certain age with CoViD-19 are not being treaded is a serious misunderstanding. Instead, when the healthcare system is faced with more critical patients than available beds and respirators, it may be forced to prioritize the treatment of those who have the biggest chance of survival.
While the concept of prioritizing patients in need of medical treatment seems harsh and inhumane to the average person, most medical doctors know this to be a pragmatic reality. A reality in every single country around the world, regardless of the status of the economy or the healthcare system. The difference between countries is the extent of this prioritizing, which can make it more apparent to the public. But in essence, no doctor in the world thinking realistically can hope to do everything and anything possible to save every single patient.
This is not something we are exactly taught in medical school, but the reality of it hits us little by little in all clinical subjects we attend and study for, until we - subconsciously most of the time - start working with this principle as a given. Only those who specifically study public health and healthcare system management have an in-depth understanding of the matter, but the principle is not that difficult to understand.
The resources spent on a patient are taken from another
Resources in healthcare involve everything, from the time medical staff dedicates and the room occupied by a patient, to the medicine given or the stitches used. Because, no matter how you see it, all of this is finite. In the world we currently live in, this means it costs money. And unfortunately, no healthcare system or government in the world has an infinite amount of money or resources.
I’m sure that some of you are already getting enraged reading this. It is, after all, considered abhorrent to talk about human lives and money in the same sentence. It is a very sensitive issue that few are keen to discuss openly. Yet in the modern world, the two are inevitably interconnected. Any healthcare practitioner who denies or does not understand that, is in the end only costing more human lives. You still have the right to be enraged, but that doesn’t make the fact any less true.
Let’s take for example the expenses for a certain medication. On an individual level, doctors want of course to help their patients as much as possible, but on a hospital or regional level, the cost for any treatment has to be weighed against its expected benefits. This is similar to the Benefit-Risk Assessment I talked about when explaining the meticulous process a coronavirus vaccine needs to go through.
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That is because every healthcare system has to decide where to dedicate its finite resources, otherwise it would go bankrupt, unable to help any patients in the end. Public hospitals and healthcare systems may not be traditional businesses, but they still have to buy and maintain equipment, as well as pay their staff. That is why they have budgets.
Choosing or allowing to spend resources (i.e. money) on a treatment with little expected effect, like giving one or two weeks of life on the respirator to elders with serious underlying conditions, means those resources are taken from another group of patients. Maybe children with cancer who might get a few extra months or even years of life by testing an experimental treatment. In developed countries and in times of peace, the decisions are never that clear or that harsh in practice, but this is what it always comes down to.
The importance of prioritizing
While doing everything possible to help every patient we meet as doctors might feel like a necessity, the alternative simply being too inhuman to consider, the bigger picture makes things much more complicated. Since no one has infinite resources in healthcare, decisions must be made on what should be prioritized.
Healthcare systems that fail to systematically and methodically take this into account, eventually find themselves not having enough bandages or antibiotics in their hospitals while having their ICUs filled with terminally ill patients who are, even with intensive care, not expected to survive more than a few weeks.
What may sound like a no-brainer on the individual level, is in reality catastrophic and paradoxically inhumane on a population level. It is simply unsustainable for doctors to try and treat every patient like they would a family member. Both emotionally and in terms of resources. Most doctors should understand this, regardless of where they work. Well, except if they work in the private sector and don’t mind sucking their patients dry, but even then, the healthcare system pays a significant prize.
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Of course, this prioritizing is much more apparent in developing and poor countries, where such hard choices need to be made on the front lines every day. Many are suffering and dying by preventable or treatable diseases, because these healthcare systems cannot afford wide vaccination programs or expensive treatments, if they are to treat the more common and simple ailments of their people. If we thought our countries were above such painful limitations however, the coronavirus has emphatically proven otherwise.
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As I’ve described above, the scariest scenario for every country in this pandemic is the possibility of ICUs overflowing with coronavirus patients in need of respirator support. This leads to a huge amount of completely avoidable deaths and preventable suffering, since patients (affected by CoViD-19 or any other serious condition) with good chances of survival would not have available beds or respirators to help save their lives. Italy has thus far been the most prominent example of how destructive this scenario can be.
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Yet, even in countries that haven’t experienced such an overwhelming coronavirus wave or have managed to flatten the curve so far, reports have circulated that the elderly are left out of hospitals. Take for example the country where I work as a medical doctor, Sweden. Many seem to believe that Sweden’s healthcare system has decided to exclude older patients with CoViD-19 from intensive care, 80 years of age being waived around as the alleged upper limit. This widespread misconception seems to have originated from a poor understanding of official healthcare documents published in April, as reported by Swedish media.
80-year-olds of different ages
The crucial distinction here is between chronological and biological age. There is no exact way to measure one’s biological age, but we can make quite useful clinical approximations. An extreme but simple example is that a teenager with multiple serious chronic conditions that require constant oxygen treatment and breathing support could have a higher biological age than their parents. That’s because one or more of their organ systems are compromised and extremely vulnerable.
Chronological age does indeed correlate with deteriorating heart and blood vessel function, affecting one’s biological age, but so does poorly controlled childhood diabetes and chronic lung disease, regardless of age. A more or less healthy 80-year-old would thus have a much “younger” biological age than a 70-year-old with advanced lung cancer and a prior heart by-pass.
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This isn’t an age contest of course; the biological age of a person is more than a simple number. It is an estimate that reflects an individual’s chance of survival in case of serious health complications, like acute respiratory failure caused by the coronavirus. Those left without respirator support in Sweden for instance, are those determined by highly specialized healthcare professionals — and their guidelines — not to have any chances of survival in the end, with or without a long, arduous and costly ICU treatment.
We are talking about people who might survive a few more weeks on a respirator but would never be able to get discharged from the ICU, their lungs unable to function without respiratory support after the damage done by CoViD-19. This is not a new practice adopted for this pandemic, but a standard practice in the country.
The same principle is applied to candidates for organ transplantations around the world, where older people and those with serious underlying conditions end up so low on the transplantation lists, that they practically never receive a transplant. Not because their lives are worth less, but because they are very unlikely to survive the procedure and/or following immune-suppressing medication required. The few available organs are thus given to those who have a much better chance of living quality lives with them. The practice is widely accepted in this field, only because the limitations are far more apparent and seemingly inevitable.
The prioritizing happening in Italy during this pandemic has some variation of the same logic behind it. But the line there had to be drawn down to scary levels, because of the unexpectedly massive increase of critically ill patients.
Medicine is about more than extending life
It is easy to focus on patients not receiving all the help they can get from the healthcare system for prioritizing reasons, and judge this to be a cruel practice. But as I explained above, the bigger picture is unfortunately not that simple. Choosing to spend our healthcare system’s limited resources on such patients, means that we are taking them from others with much better chances of meaningful survival.
It’s a very sad, but unavoidable reality for us doctors: we cannot save everyone. We cannot even afford giving 100% to try and save all who might have the slightest chance of surviving one more day. Because even if some lucky ones manage to beat all odds and survive, their shortly extended lives could hardly be called human.
Modern medicine has been steadily moving away from the impossible effort to save all patients in the moment, and towards reducing suffering for as many patients as possible in the long term. These two goals are surprisingly often conflicting, especially when it comes to terminally ill patients. And this is where palliative care has made enormous strides in recent decades.
Fighting to prolong life by any means possible does not only come with a cost for quality of life, but also with unneeded suffering for our sick and elderly. The sooner we understand this, the sooner we can start concentrating on improving life, rather than postponing its inevitable end.