The Cost of Life

Many of us have cared for patients like the hypothetical one I describe here: a middle-aged man with multiple serious comorbidities, including end-stage renal disease requiring hemodialysis, who presents with complicated septic shock. We think that our first examination of the patient could very likely be the last. When the risk for death is high for a patient, many health care providers believe that moving toward hospice or comfort care may be best, not only for the patient but also financially for the family and hospital system. In these situations, sometimes “doing everything” for the patient is recognizing early that a patient will likely not survive their illness and transitioning care sooner. However, as noted by Faber-Langendoen and Lanken in Annals of Internal Medicine, few ICU patients can make decisions about withdrawing treatment, leaving providers to depend on surrogate input (1). Many families’ vision of “the best care” often equates to a prolonged ICU stay on mechanical ventilation, numerous days of antimicrobials, multiple pressors, and renal replacement therapy despite a poor prognosis, leaving providers to put price tags on treatments and ultimately on people.

During the care of such patients, it is common that family members become familiar faces in the ICU. We often get to know them by first name and they are often kind. When we speak with them when they visit, they talk about what their life was like at home before this tragedy. We also spend time talking about more difficult things—specifically, goals of care. It is common that they say their loved one would want "everything done" and that they also want "everything done to save their loved one." Often this is expressed at a time when the patient is actively dying despite receipt of multiple drugs, including pressor support; multiple invasive procedures; and mechanical ventilation.

When patients’ family members want “everything done,” we think about what more we can do and resort to unproven “Hail Mary” interventions. Often there is disagreement among the members of the medical team about providing such interventions. Almost always the patient dies regardless of whether the last resort intervention is attempted.

I’ve spent some time thinking about patients like this that I have cared for, thinking about the value of life and the costs associated with critical illness in the ICU. In 2001, Slim Watson, known as the “million-dollar man,” spent 34 days in the ICU at Duke resulting in a final bill of $5.2 million (2). Some drug costs reached as high as $6,800 a vial and $250,000 a day. Despite these high costs the patient unfortunately had a bad outcome (3). This often is the painful clinical reality for patients in the ICU. Medicine today is centered on balancing the need to control costs with delivering the best care to complex critically ill patients. As a resident, I find this difficult to balance.

It remains unclear to me what our medical system would consider a “reasonable cost” for a human life. In the eyes of a patient or a family member, the cost could never be too high. In the eyes of a physician, several factors are often considered. Patients who are elderly, have poor functional status at baseline, and have many comorbidities tend to have higher mortality both in and out of the ICU setting compared with patients who do not have these characteristics. While all patients should receive high-quality care, this is the patient population that places the utmost strain on our health care system.

References

1. Faber-Langendoen K, Lanken PN. Dying patients in the intensive care unit: forgoing treatment, maintaining care. Ann Intern Med. 2000;133:886-93. [PMID: 11103059]
2. Ranieri VM, Thompson BT, Barie PS, et al; PROWESS-SHOCK Study Group. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366:2055-64. [PMID: 22616830] doi:10.1056/NEJMoa1202290
3. Lees K. A question of limits. Duke Today. 24 August 2001. Accessed at https://today.duke.edu/2001/08/healthecon824.html on 29 December 2021.