Life, Death and Money in the ICU
我工作的重症监护病房的一位病人因为一种对所有已知抗生素均有抗体反应的感染正在濒临死亡。重症监护病房里的所有医生都认为这个病人活下来的几率几乎为零。但是，负责治疗该名患者的外科医生仍抱有希望。目前，该名男子已经在重症监护病房住了六个月。他的治疗费用已经超过150万美元。虽然他上有医疗保险，但是他的家人已经捉襟见肘，以至于连开车到医院的汽油费用都险些拿不出来了。iStockphoto在美国，我们将一半的医疗保健费用都花在了病人最后的六个月里，这段时间很多患者都不得不呆在重症监护病房。如果我们想要控制不断攀升的医疗成本，我们就必须想方设法更好地应对象该名患者一样的病人所面临的现实困境。医生很少会对患者家属谈起高昂的治疗费用以及许多病人面临的经常是严酷的死亡预告。这在一定程度上是因为医生自己发现很难放弃治疗。医生的天职就是尽一切可能挽救病人的生命，而他们也将死亡与失败联系在一起。此外，医生通常对他们所提供的治疗方案的效果过于乐观。任何速效疗法或者旨在监管重病病房的盲目政策都无法解决这个问题。我们需要象对待疾病一样来审视这个问题：我们需要进行科学研究，更好地了解问题的根源和可能的解决办法。目前，我们只是靠直觉。我们是否应该确保每周与病人家属举行会议？我们是否应该把预测的治疗后果以及成本的详细资料告知患者及其家属？家属是否应该为那些存活希望非常渺茫的患者支付更多的医疗费用？是否应该由独立的医生而不是患者自己选择（因而感情上更加依赖）的医生来预测病情发展？任何解决办法都有可能导致我们不愿意看到的后果或者全新的问题。重症监护病房犹如一个脆弱的生态系统；即便是很小的变动也会对临床道德社会和经济等很多方面产生深远的影响。因此，我们应到谨小慎微，在进行大规模的改革之前，研究不同的方法。然而，用于研究此类问题的联邦资助实际上根本就不存在。每花费在研究新药和流程上的一美元，只有几分钱是用于研究和改善医疗服务的具体实施上。可是这些都是异常复杂的问题，高成本高科技，还与基本的生命和死亡的人权问题息息相关。因此，即便我们可以拿出更好的办法，我们也需要根据个人的具体情况留有变通的余地。最近，我工作的重病特护病房的一名年轻女性因为患有心脏衰竭和感染而挣扎在死亡边缘，而且我们所建议的疗法当中无一有效。她存活的可能极为渺茫。不过，该名患者虔诚的家属相信奇迹会出现，因而不愿放弃治疗。最后，她在重症监护病房住了六周之后，我告诉她的家属我们已经无能为力，并且提出和他们一起为病人祷告。我们一起祷告着，希望渺茫和毫无希望之间的距离渐渐缩小了。第二天，我们拔掉了她的生命线。PETER PRONOVOST, M.D.（编者按：彼得•普罗诺弗斯特(Peter Pronovost)是约翰霍普金斯医学院(Johns Hopkins School of Medicine)麻醉学和急救医学教授。）
A patient in the intensive care unit where I work is dying from an infection that is resistant to all known antibiotics. None of the intensive care physicians who staff the unit think the man has any chance of being discharged alive. But the patient's surgeon, who is in charge of his care, has hope.The man has been in the ICU for six months now. His care has cost more than $1.5 million. He has insurance, but his family is so strapped that they have difficulty affording gas to drive to the hospital.As a nation, we spend half of our health care dollars during the last six months of a patient's life, a time when many patients wind up in the ICU. If we are ever to control rising health costs, we will have to do a better job confronting the realities for patients like this man.It's rare for doctors to talk with families about the high costs and often grim prognoses many patients face. This is partly because physicians themselves find it hard to let go. Doctors are trained to do everything in their power to keep a patient alive, and they associate death with failure. And doctors tend to be overly optimistic about the benefits of therapies they offer.Quick fixes or blind policies that attempt to regulate the ICU will not solve this issue. We need to examine this as we would a disease: We need to do scientific research to better understand the root causes and possible solutions. Right now, we have only hunches.Should we ensure weekly family meetings? Should we provide patients and their families detailed information about prognosis and costs? Should families incur more of the cost for patients with low likelihood of survival? Should independent doctors, rather than the patient's own emotionally invested physician, estimate prognosis?Any solution might create unintended consequences or wholly new problems. The ICU is a fragile ecosystem; small changes can have wide reaching clinical, moral, social and economic effects. So we should tread carefully, and study different approaches before making broad changes.Yet federal funding for studying these sorts of things is virtually nonexistent. For every dollar spent researching new drugs and procedures, only pennies are spent researching and improving the delivery of care.These are complex issues -- high costs and high-tech treatments, bound up with basic human questions of life and death. So even as we work to come up with better approaches, we need to leave room for human variation.Recently, a young woman in the intensive care unit where I work was dying of heart failure and infection, and none of the recommended therapies helped. She had little to no chance for survival.But the patient's devout family believed in miracles and did not want to withdraw support. Finally, after she had spent six weeks in the ICU, I told the family there was nothing else we could do, and I offered to pray with them. We prayed, and the gap between little and no hope narrowed. We withdrew life support the next day.Peter Pronovost is a professor of Anesthesiology and Critical Care Medicine at the Johns Hopkins School of Medicine.PETER PRONOVOST, M.D.
A patient in the intensive care unit where I work is dying from an infection that is resistant to all known antibiotics. None of the intensive care physicians who staff the unit think the man has any chance of being discharged alive. But the patient's surgeon, who is in charge of his care, has hope.The man has been in the ICU for six months now. His care has cost more than $1.5 million. He has insurance, but his family is so strapped that they have difficulty affording gas to drive to the hospital.As a nation, we spend half of our health care dollars during the last six months of a patient's life, a time when many patients wind up in the ICU. If we are ever to control rising health costs, we will have to do a better job confronting the realities for patients like this man.It's rare for doctors to talk with families about the high costs and often grim prognoses many patients face. This is partly because physicians themselves find it hard to let go. Doctors are trained to do everything in their power to keep a patient alive, and they associate death with failure. And doctors tend to be overly optimistic about the benefits of therapies they offer.Quick fixes or blind policies that attempt to regulate the ICU will not solve this issue. We need to examine this as we would a disease: We need to do scientific research to better understand the root causes and possible solutions. Right now, we have only hunches.Should we ensure weekly family meetings? Should we provide patients and their families detailed information about prognosis and costs? Should families incur more of the cost for patients with low likelihood of survival? Should independent doctors, rather than the patient's own emotionally invested physician, estimate prognosis?Any solution might create unintended consequences or wholly new problems. The ICU is a fragile ecosystem; small changes can have wide reaching clinical, moral, social and economic effects. So we should tread carefully, and study different approaches before making broad changes.Yet federal funding for studying these sorts of things is virtually nonexistent. For every dollar spent researching new drugs and procedures, only pennies are spent researching and improving the delivery of care.These are complex issues -- high costs and high-tech treatments, bound up with basic human questions of life and death. So even as we work to come up with better approaches, we need to leave room for human variation.Recently, a young woman in the intensive care unit where I work was dying of heart failure and infection, and none of the recommended therapies helped. She had little to no chance for survival.But the patient's devout family believed in miracles and did not want to withdraw support. Finally, after she had spent six weeks in the ICU, I told the family there was nothing else we could do, and I offered to pray with them. We prayed, and the gap between little and no hope narrowed. We withdrew life support the next day.Peter Pronovost is a professor of Anesthesiology and Critical Care Medicine at the Johns Hopkins School of Medicine.PETER PRONOVOST, M.D.