Is Money the Root of all Evil?

Recently, I watched a gripping and provocative movie, entitled “Critical Care.” In fact, I viewed it 3 times in 10 days! It reminded me how brilliant advancements in medical technology can sometimes be more burdensome than useful.

In the movie, there are several patients in a critical care unit whose medical condition has overmastered their bodies. Yet, because of advanced medical technology, they are kept alive with various machines and tubes.  Because, if any tube is disconnected, they would die.

A major message in the movie “Critical Care” is this: money collected from a person’s health insurance is oftentimes the determining factor in continuing futile medical care.  After viewing it, I felt compelled to write about ethical issues and futile medical care. My husband and I had written an article about this dilemma 20 years ago. After viewing this movie, I concluded that not much has changed when faced with this dilemma.

Futile medical care is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.  

The movie shows how medical futility causes emotional turmoil for everyone involved including the patient (if conscious), family, physician, nurses, and hospital administration.

Who speaks for the patient in a coma when family members, physicians, and hospital disagree on whether to continue or discontinue futile care?  

To be sure, the most important person is the patient. But, sometimes as depicted in the movie, most of the attention is directed to the patient’s treatment and less to their perspective and preferences. In these special units, the patient is oftentimes heavily sedated or in a coma.  And, unless the person has an advanced directive (or a living will) their voice is not heard. An advanced directive explains one’s treatment preferences if the situation arises where they cannot speak for themselves. About 37% of US adults have an advanced directive. This means that the majority of patients’ families will have to guess the patient’s preference to continue, withhold, or withdraw treatment based on the patient’s medical condition.

In the movie, one such patient is an elderly man who has been in a coma for 3 months.  He does not have an advanced directive that explains his end-of-life treatment preferences. He is referred to as Bed 5, indicative of the limited emotional bond between the care team and patient. Bed 5 is unable to share his feelings and thoughts about life or death. If he could speak, what would his thoughts be especially after being in a coma for three months?

Should cost factors be considered?  What motivates the responses of those involved?

First, the value of a human life is priceless and deserves to be respected and honored. The patient always deserves compassionate care and treatment that will improve the quality of their life. But, an ethical dilemma ensues when care extends for months with no signs of recovery. It is reported that the average cost of one day of futile treatment in an intensive care unit is $4000. In the movie, the hospital is collecting over $100,000 a month for this patient’s care and the attending physician does not want to stop this financial windfall.

The primary patient (Bed 5) is typical of some patients in intensive care or critical care units. He has been in a coma for three months.  Except for the stomach, he has tubes in every other vital body part. And the attending physician wants to add one more, to connect the stomach to a feeding tube.  Indeed, the advancements in medical technology make it possible to keep a person alive indefinitely. But, is this compassionate care? Will it improve the quality of his life?  Would this scenario be different if the patient had an advanced directive or living will? Since he has neither, the primary physician of record is making the health decisions for the patient.

Unfortunately, this attending physician is guided or perhaps misguided by money. His philosophy: patients with good health insurance coverage should remain in the hospital as long as possible. For him, keeping a patient in the Critical Care Unit was highly profitable even when the medical situation is futile.

Then, there are family members in the movie, two sisters who are at odds with each other about what is the proper medical treatment for their critically ill father.  One daughter wants everything science has to offer to keep dad alive. Frequently quoting scriptures, she uses the Bible to justify her rationale. She is convinced that he responds to her in his comatose condition. Her worldview appears to align with a large percentage of the US population. According to a 2013 Harris Poll, 72% of Americans believe in divine miracles. This may help to explain the small number of people who have advanced directives. Are they hoping for a miracle?

The other daughter wants to discontinue futile care and let dad die peacefully. Most of her conversations with the resident physician are interrupted by exaggerated crying spells about her father’s condition. She uses her emotions to manipulate the critical care resident physician.

In this storyline, both sisters’ motives are shrouded by a huge financial inheritance one or the other will receive based on the timing of his death. While monetary gain may play a factor in family decision-making in real life health issues of loved ones, it was not something that could be documented in my research. After all, who would admit to having such selfish and ulterior motives?  Quite the contrary. Discussions with the doctor about limiting treatment in cases of futile care is difficult. The emotional attachment weighs heavily as families hope and pray for a miracle or at least gradual improvement.

The movie has several twists and turns. There is the critical care medical resident, the physician providing the primary care to the patient (as is usually the case in training hospitals).  Medical residents are physicians who have completed medical school. During residency, physicians are trained to acquire expertise in their specialty of choice. He finds himself in a legal bind after having a brief affair with one of the patients’ daughters (a definite no-no!). Fortunately, he is able to wiggle himself out of the situation.  And, by the end of the movie develops genuine compassion that honors the humanity of the patient in bed 5. Indeed, it is nice to see the story humanize at least one of the doctors.

This narrative describes the responses of physicians and family members to a comatose patient with tubes connected to each body orifice and who has not responded to medical treatment for several months.  How are situations like this best handled?

Indeed, advanced medical technology has its place. Research by brilliant physicians and scientist must continue. Indeed, it saves lives and enhances quality. However, death is still an inevitable occurrence for all of us. And at some point, advanced treatments will not lead to recovery.

An advanced directive or living will expresses one’s end-of-life care decisions. Most importantly, it allows one to voice their own treatment choices when they are of a sound mind. The burden is not placed on family members, physicians, or hospital administrators. When you plan ahead, you avoid unnecessary suffering and loved ones don’t have to make decisions for you.

End-of-life situations can occur at any age. Therefore, all adults are recommended to complete an advanced directive.  This can be accomplished with or without an attorney. This document can be obtained online and is free. Plus, many doctor’s offices and hospitals allow you the option to complete one while you are in their office. Here is the link to the State of Georgia’s online advanced directive. https://eforms.com/power-of-attorney/ga/georgia-advanced-directive-for-health-care/

Please google your state’s document if you do not live in the State of Georgia.