'The Health Care System: Part 3'

CAERS SUBSTACK ARTICLE #59

‘The Health Care System: Part 3’

CAERS Substack Article #59

The traditional Health Care System (HCS) at some point must face the reality that every individual who seeks its services will eventually die. In other words, although its focus is returning patients to good health when afflicted by injury, disease or illness, it will inevitably fail every patient and the system would be well-advised to find the best ways to deal with that unfortunate reality.

The challenge facing any HCS is that preventing disease and illness, treating disease and illness, and easing patients from disease and illness towards death are three very different things. The first two of these might be easier to distinguish potentially, but the transition from the second to the third is not nearly so distinct. We may take extra vitamin D and calcium to prevent bony fractures, but when your tibia is protruding through your shin at the bottom of the ski slope it will almost certainly require the services of an orthopedic surgeon. But at what point do we accept without reservation that no reasonable treatment is available and allow the final journey of life to begin?

Over the years I have heard many quotes that document the amount of money spent on health care in our last years of life. I have heard it said that, on average, 80% of all money spent on a patient’s health care during their lifetime is spent during the last 6 months of life. I have also heard that it is 50% in the last year. Regardless of the exact numbers, it is likely true that the final years of life, when multiple body systems are failing and the diseases encountered are complex, will be the most challenging, and not surprisingly most costly, to manage. Given such statistics, one could make a case that the Health Care System would be better referred to as a Death Care System.

It is certainly not unreasonable to spend ample funds to make the final months or years of life as pleasant as possible. But the sad truth is that far fewer resources are used in providing good palliative care than are used in an attempt to prevent death itself. We humans tend, in the words of Dylan Thomas, to “rage, rage against the dying of the light”. That is likely the nature of all living things; the mystery of life is a precious gift that we do not surrender easily.

One of the greatest deceptions we use to convince ourselves that the postponement of death as long as possible is justifiable, is that we will ultimately save money by keeping people healthier so as to live longer. But clearly no matter how much healthier we make people or how much longer they live, everyone must still die.

I am a senior citizen now and I am no longer contributing to the economic productivity of society, although I hope to be contributing in other non-financial ways. I am using both my personal savings and government plans to maintain my lifestyle, and availing myself of more HCS resources in a way I have not done before in my life. Keeping me alive longer, to incur more deterioration and medical complications, is never going to save my children or grandchildren money in the end. That doesn’t mean that we should look at financial cost as the only or most important factor in medical decision-making. But it does mean that we must accept that I am going to be a progressively heavier user of the resources and capital of the HCS. Each passing year it will become more expensive to sustain me, and at some point, I don’t want my grandchildren to be deprived of an education, for example, simply to allow me to forestall the inevitable.

These are tough topics to discuss. They are scary and painful. But they don’t disappear simply by not dialoguing about them. If we had unlimited resources, not just money but also personnel and time as well, we might be able to avoid them, or postpone them for much longer. But in the real world we have to balance many aspects of our lives, not just health; like death itself, difficult trade-offs are simply inevitable.

Is any of this relevant to the pandemic? Have we been able to have these painful, but potentially helpful discussions? If so, have they been worthwhile? If not, might they be valuable for the future? As long as time goes forward not backward, and for as long as mortality remains a reality for us, these issues will continue to challenge us.

J. Barry Engelhardt MD (retired) MHSc (bioethics)

CAERS Health Intake Facilitator