Introduction
In the past, limited treatment options give patients, families, and medical professionals little leeway to decide on keeping patients alive or letting them die as the progression of the disease would almost always make this decision of them. Today, advancements in technological innovation have enhance the capabilities of modern medicine. An increased range of options makes it possible to keep terminally ill patients in an eternal, animated state where all vital bodily functions are sustained. However, the patient still remains unconscious and confined to intensive care hospitalization indefinitely.
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The availability of this options has further confounded the making of end of life decisions. Even as physicians push the boundaries of modern medicine by going above and beyond to improve patient outcomes, the limitations of medicine at the brink of death have never been more apparent. This paper is the author’s reflection on the film, facing death and its depiction of end of life opinions, culture, and the cost of intensive care.
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Opinion on End of Life Decisions
Making end of life decisions is complicated for patients, families, medical professionals, and policymakers. When a patient’s prognosis is abysmal, the physician has to respect the patient’s autonomy, provide information, prioritize the patient’s self-determination, and preserve life. However, patients often lack sufficient information about the options available for them or are unable to understand the options provided enough to make informed decisions. For instance, in the film, John is facing severe complications from his struggle with multiple myeloma and the aftermath of a stem-cell transplant. When his doctor explains to him the options available for him, he does not seem to understand. His wife has to clarify what the doctors meant when they asked if he wished to continue treatment given his prognosis, retire to a hospice or sign a Do Not Resuscitate (DNR) order.
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Family members have long been considered an invaluable unit in making end-of-life decisions for their loved ones. However, as can be deduced from the case of Martha, family units may know very little about what to do with their loved one at this critical time. Martha’s family seems divided as to whether to allow doctors to perform a tracheotomy on their ailing mother or stop treating her entirely. One of her two daughters wants the doctors to do as much as possible to keep Martha alive as she believes she does not have the authority to decide on her mother’s behalf. Martha’s other daughter feels that there is a need to exercise compassion and grant their mother the opportunity to die with dignity.
According to the care team, Martha’s Alzheimer’s has progressed so rapidly that it is likely that she will have to be intubated again. Moreover performing a tracheotomy is expected to bring her additional pain and suffering. However, the family chooses to go ahead with treatment, which leaves their mother confined to an Intensive Care Unit (ICU) for a year after her initial hospitalization. It is unlikely that further treatment is improving Martha’s quality of life and quite possible that her family is prolonging therapy out of fear of making a premature decision or being in denial about their loved one’s prognosis.
End of life decisions are even more challenging to make for the physician. In the film, doctors try to advise patients on the options available for them, while being careful not to expose professional or personal bias. Norman’s physician expresses guilt for having performed the transplant. She feels that he would not have died so painfully had she not done it. Although patients can recover from a potentially life-threatening illness as a result of an intervention, it is also likely that the intervention could expedite the patient’s decline. This uncertainty is well evidenced in the case of Albert, who has undergone two stem cell transplants and was awaiting the results of deliberations among his physicians so he could have another. It certainly is challenging to weigh the option of treating someone with procedures that might kill them or waiting for them to die from an illness.
Culture
American individualistic culture informs most policy decisions. Thus, it is not surprising that the individual, and not the family, is given primary consideration when making end of life decisions. If individuals are unable to make health decisions for themselves, they are advised to have a health proxy, a person whom they inform of their preferences at the end of life, and who is supposed to abide by these directives until the patient decides otherwise. An illustration of individualism is the case of Norman, who has appointed his sister as his legal proxy. When he expresses interest in signing a DNR to his girlfriend, the care team confirms from Norman if he does indeed feel that way.
Individuals from collectivist cultures allow more family control over end of life decision making. Martha’s first daughter is ready to let her mother go without consulting with Martha first. She feels this decision shows compassion for her mother’s suffering and will enable her to die with dignity. However, her sister, who seems more inculturated into American individualism, vehemently disagrees. She feels that making that decision should not be their prerogative. It was difficult to witness what happened to Martha when a conflict between individualism and collectivism generated a collectivist decision to keep her confined the intensive care unit indefinitely. Had Martha appointed a health proxy and stipulated what her preferences in terms of treatment were, her family may not have been so divided.
Cost of Care
In the film, Albert undergoes tow stem cell transplants, both of which fail. The combination of aggressive treatment and his illness takes a toll on him, leading to his ultimate demise. It is daunting to consider that his treatment may have been futile, done more harm than good, and placed an incredible financial burden on his insurance, which may be transferred to the larger society through higher premiums. Only 5%of all patients admitted to hospitals require treatment in the ICU (Kılıç, Yüzkat, Soyalp & Gülhaş, 2019). Although this number seems minute, ICU spending may account for up to 30% of a hospital’s budget (Kılıç et al., 2019). ICU admissions are associated with the complications of serious illnesses, the need for specialized testing, the need for expensive equipment, the need for specialized medical attention and round-the-clock attention from other hospital staff. Even in patients with a promising prognosis, the cost of this kind of care is substantial (Kılıç et al., 2019). Central to healthcare spending reform is the notion that close to 30% of all health spending is wasteful (Doyle, Graves & Gruber, 2017). This idea is driven partly by the concern that hospitals are subjecting terminally ill patients with suboptimal prognoses to intensive treatments that yield no apparent benefit in terms of health outcomes or quality of life. The high costs of care place a significant burden on the taxpayers and policymakers as they attempt to justify denying people treatment to preserve scarce resources.
Conclusion
End of life decision making is a challenging task for everyone involved. It is difficult for some patients to grasp the idea of their mortality. Similarly, family members may find it challenging to decide on a life that is not their own. Healthcare providers face the daunting task of balancing the greater good they feel will come from harmful treatment with their obligation to respect the patient’s autonomy. Given the high costs of intensive care hospitalization, there is a need to simplify end-of-life decision making for all parties involved.
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