For some years I have been writing about end-of-life care and, of late, focusing on the high costs of that care. I recently had a painful but revealing insight into what the future might look like on both costs and decision-making. It came about from an unexpected angle of vision, the care provided by a veterinarian in an emergency care center for pets.
Our much loved dog, Sunny, a 6-year-old Cavalier King Charles, otherwise in good health, began throwing up, ignoring her food, and displaying untoward lassitude. The symptoms got worse within a few days and we took her to a neighboring pet hospital, one that advertises a range of available technologies and treatments equal to that found in a hospital for humans.
We took her in the morning, left her there, and in the late afternoon were told that she had kidney failure, was unable to pass urine, and had other serious symptoms. The prognosis was not good, but it would take another day or so to see what difference treatment might make. She gradually went downhill the second day, a catheter failing to bring forth much urine and with increased signs of distress.
At the end of that first day, we were given a detailed set of cost projections. We were required to put up, via credit card, $2,600 as part of an estimated cost of $5,000 or so for two days of intensive care — a treatment plan that could come to $9,000 if it went on for more than three days. I had read about the high cost of upscale veterinarian care, but it had never occurred to us that we would have to face it.
Yet if the projected costs were jolting, something else was no less arresting: the time and care the chief veterinarian in charge of Sunny’s care took to explain exactly what was going on with Sunny, what they were doing, what the prognosis was — and how rapidly the costs would continue to rise if Sunny survived. She was equally frank about the fact that Sunny was not likely to make it and what it would cost us if she did. The veterinarian told us in a way that beautifully integrated money, medical candor, and compassion. It was, I thought as she was doing so, just what we might hope for from a doctor for our care, but by no means yet reliably available.
We agreed at the end of the second day that we would see how Sunny did overnight. If there was no improvement, we decided it would be best to put her to sleep (I don’t believe her doctor ever used the phrase “put her down”). She did not improve, required oxygen during the night, and passed little urine. Sunny’s doctor called us early the next morning to report the bad news, and I told her to stop. It was both a hard and an easy decision. Emotionally it was hard to say stop, but easy because it seemed the only reasonable decision, and the doctor readily assented.
What will stay in my mind in addition to the pleasure Sunny brought us in her relatively short life — she was always at our side or in our laps — was the doctor’s combination of sensitivity and telling the truth. There have been some important medical journal articles in recent months on the importance of restoring the ancient skill of prognosis, long in decline, to end-of-life care for people. Patients and families need to have some sense of what the future will bring, even if it is uncertain. They need to know the likelihood of death and also what may ensue if a very sick patient survives: what then? Our veterinarian said that if Sunny were lucky enough to make it she would likely remain in poor health, requiring considerable future medical care. Our doctors often fail to tell patients and families about just that disturbing likelihood. Seeing it well done by our vet underscored its value, for our pets and for us.
But my most telling glimpse into the human future came with the introduction of cost as an upfront consideration, something I believe will soon become common in our health care, perhaps even routine. For us, the $5,000 charge for Sunny’s care was bearable, but the prospect of the cost of successful treatment, had that been possible, would surely have given us pause. I am sure we would have said at some point that, financially, enough is enough, but I am not certain just when that might have been. I am convinced, however, that the future will force us to deal directly with the high, and in many cases insupportable, human costs of end-of-life care and to stop treatment for that reason. Sunny’s quick decline spared us that decision, which was a blessing in a way.
I was left with some troubling thoughts. Would it have been better if veterinarian medicine had not moved into the high-technology realm once reserved to humans? My wife and I both had dogs (and sometime cats) as we grew up. When they got sick they just died or were put down to save them from misery. I don’t recall anyone thinking that state of affairs was an evil. Are we better off now with that our pets have access to expensive, high-technology medicine — and are they? And how much better off are we as humans because of the way we now often die, sometimes lingering on for years, the beneficiaries, and sometimes victims, of a medicine equal to what our pets can now have? For me, those questions were left hanging in the air.
Daniel Callahan, cofounder and President Emeritus of The Hastings Center, is coeditor of the Health Care Cost Monitor. This essay originally appeared in Bioethics Forum.