Dr. David Tribble

I read with interest a recently posted interview with President Obama on the subject of the peculiar American approach to the end of life, which is more a violent struggle against death. He recounted a situation with his grandmother in which she was suffering from a terminal illness and then broke her hip, raising questions about the propriety of repairing a hip in a terminally ill patient, at the individual and at the societal level. It posed the conflict between the personal result of pain and immobility if the hip were not repaired and the societal cost of hip repair in patients who might not live long enough to justify the intervention, however that might be measured.

I was struck by the assumption that the conflict will always be framed in terms of personal benefit vs. the cost to society. That assumption is simply not accurate. We have well-done studies that show the failure of CPR in end-stage disease; the inability of TPN (total parenteral nutrition, or intravenous feeding) to prolong survival in end-stage cancer; and the futility of 3rd and 4th line chemotherapies in most cancers. Yet we continue to provide these treatments as if failing to provide them somehow short-changes the patient. These therapies do not provide the clear-cut benefit that repairing a broken hip provides, and, in fact, it can be argued that they provide no benefit at all.

I propose, then, that the discussion should start not with the struggle between immediate benefit to the patient and long-term benefit to society, but with absurdity of spending resources that are rapidly diminishing on therapies which we know are ineffective (but which we employ simply because we cannot stand not to). We don’t have to start with challenging therapies that offer a 20% or 30% chance of benefit. We should start with challenging the ones that offer 0% chance of benefit. That, alone, would save hundreds of millions of dollars.

Most hospice physicians I know wouldn’t hesitate for a second to repair the hip, unless the patient were unlikely to survive the surgery. We draw the line at treatments which impose burden without benefit, which is a rational viewpoint for all of medical practice.

Dr. David Tribble is Alive Hospice’s chief medical officer.