I Am the Problem in Health Care

I confronted the banal face of our inefficient healthcare system, and it stares back at me in my mirror.

David was 98 years old, and a successful owner of art galleries in Boston, New York, and Naples. In World War II, he was a B-24 Liberator pilot, and was shot down over Europe. He raised a family. His bone marrow has failed and he no longer responded to Procrit or Neupogen. He was no longer making red or white blood cells. He was tired, with an hematocrit of 17, and a white count below one. He was transfusion dependent, and the hematologists had little more to offer. His PCP would no longer follow him in the nursing home, so I inherited him one week ago.

"David," I gently started, "Your blood counts are low again. Do you want another transfusion?"

"I lived a good life. Nobody lives forever. I never needed to live to 100."

"Are you comfortable?" I pressed on.

"Yes, I made a good living, thank you."

Humm, this wasn't moving in the right direction.

"The last time you said, 'Enough, already.' Are you comfortable now? Should we just let you be, keep you comfortable, and let your life come to its natural end?"

"Ask my son. Let him decide."

"But," still looking for guidance, "what should I tell him when he asks how you feel about continuing the transfusions?"

"Tell him I lived a good life. Nobody lives forever. I never needed to live to 100."

OK. I call the son.

"I want him transfused. He should be getting his blood checked every week." I'm dismissed. I call back ... "Look, he's 98 years old, he's lived a full life and he's comfortable. The specialists have nothing left to offer. He can't go on with transfusions every week. He'll develop reactions, complications. His immune system is so weak, his white count is so low, he's one sneeze away from a fatal pneumonia. He will never leave the nursing home. He wants you to decide about the transfusions, but I don't think he really wants to continue to live like this."

"I want him transfused."

He went to our local hospital, got admitted to Day Stay, and received 2 units of red blood cells. The bill for testing, preparing, and administering the blood was $1,139, and that did not include the round trip ambulance ride by a basic rig. He has Medicare.

The next week, I gently started, "David, your blood counts are low again. Do you want another transfusion?"

alan berkenwald, md