The Doctor’s Surgery
My greatest achievement in life so far has been my total avoidance of the necessity ever to commute to work. My second greatest achievement has been my almost equal avoidance of television for the past 50 years. This has included periods of residence in countries in which the TV had not yet arrived, which might perhaps be counted as cheating.
I have only one ambition left to me: never to be admitted to an intensive care unit (ICU).
I have on occasion been very ill – nigh unto death, in fact – but fortunately was always able to breathe and excrete for myself, and so was never forced into that bourn from which some travellers return, though often much the worse for the experience.
A recent article in the BMJ informs us that the demand for places in ICUS is rising by four per cent a year.
Treatment in ICUS is fantastically expensive. Since our economy does not grow at anything like the same rate, there must become a time in the future, assuming the trend continues indefinitely, when such treatment consumes the entire economic product of the country. However, projections are not predictions: the growth in demand must end somewhere.
According to the article, written by two specialists in critical care medicine, a geriatrician and a person described as ‘patient and public representative’ (though we are not told not what they represent to whom), it is not possible to predict with any degree of accuracy who will most benefit from intensive care.
The older and frailer the patient, the worse the prognosis; that is to say, the more likely they will emerge from the ICU in a diminished state, both physically and mentally. But, of course, patients are individual human beings and not just members of classes of human beings. I have known some very old people who have resumed their post-icu lives as if nothing had happened.
Where demand outstrips supply, some method of allocation or rationing will have to be found. The authors suggest that one possibility is to try to reduce demand by making patients and their relatives more aware of the limitations of medicine and more realistic about possible outcomes.
At the moment, keeping people alive at all costs, no matter the quality of life afterwards, is the main aim. In fact, only one in eight old people, when admitted to an ICU, is asked whether or not they want to go. In large part, this is because, by the time someone needs an ICU, they are no longer in a condition to say yea or nay. If they could only be shown a preview of the advantages of letting nature take its course and giving advance directions on the matter…
But there is one objection to advance directives: one does not really know how one will react to a situation until one is actually in it. Most people, if asked, say that they would rather die than be tetraplegic. But tetraplegics do not want to die; they mostly want to live.
Managers without any medical training used to prowl round the wards in a hospital with which I was familiar, looking for patients who could be discharged early – so that the corridors downstairs did not clog up with patients on trolleys awaiting a bed. Whether it was right, decent or kind to discharge the patients hardly came into it.
In these circumstances, I think I would opt for admission to the ICU, if only to spite the managers and make life difficult for them.