In 1973 a movie was released that has had one of the greatest and longest-standing impacts on my medical career, the importance of which was suddenly brought to light a few years ago. The movie was set in 2022, when an over-populated, under-nourished Earth was given a high-protein food supplement called ‘Soylent Green.’ It is a great movie, starring some of the greatest actors of all time, including Charlton Heston and Edward G Robinson. People over 65 years of age were disappearing at an alarming rate with no obvious cause and no corpses left behind; they simply vanished. The main character was targeted by the government because he got too close to the truth: the feeble and elderly were being recycled, becoming the source of Soylent Green, to spare the younger, more viable generations. In much the same way, the plan of the current administration and Congress to ‘cut healthcare costs’ while simultaneously ‘providing insurance to everyone’ will fall into a never-ending spiral, eventually leading to a situation where there is no choice but to provide care to some at the expense of others. Rationing and ‘selection’ of who to treat will be the inevitable outcome. Even a child knows that you cannot make more cookies with the same amount of dough unless you make all of them smaller.
I have all too often seen examples in medicine that remind me of this scenario. In fact, 90% of my new patient population hears about me by word of mouth, and their first words are: “Doctor, everyone tells us that you are our last hope—everywhere we have gone, everyone we have seen has told us we are too high-risk, so nothing more can be done.” I tell them: “sounds like Soylent Green medicine to me” and assure them: “I will do everything I can to help you and your loved one, and if I can’t, I’ll find someone who can!”
A long-time patient of mine, now 97 years of age, is an active, elderly lady who has an extremely warm and supportive daughter and son-in-law. She enjoys going to the casinos where she plays the slot machines for hours. She is ambulatory without assistance and lives on her own. They go out shopping, to lunches and dinners, and on vacations. She only stopped driving a year or two ago. She watches Jeopardy daily and yells out most of the answers before the contestants can even ring their buzzer. She has a mastery of the multimedia room and knowledge of the master remote control for the audiovisual systems and televisions that exceeds that of the rest of her much younger family.
Two years ago, she began complaining of diffuse abdominal pain, especially right after eating. It was getting so bad that she was almost afraid to eat. She was losing weight and getting weaker. Not wanting to ‘bother’ their cardiologist with this, the family took her to the local emergency room. She was seen and evaluated on numerous occasions, but nothing was ever found. After a few weeks, a computed tomography (CT) angiogram of the abdomen was finally performed. The CT revealed an extensively calcified aorta, with extension into all of the mesenteric vessels. The celiac artery was subtotally occluded, the superior mesenteric artery was narrowed by 95%, and the inferior mesenteric artery was occluded. The doctors informed the patient that she was suffering from mesenteric ischemia and intestinal angina. Two vascular surgeons, a general surgeon, and an interventional radiologist were consulted, all of whom are well respected in our community. After much consultation and discussion, they were presented with the option(s): ‘go home and die and take a lot of morphine.’ When asked why, the surgeon simply said that because of her age, the calcification, and the extent of the atherosclerosis, she was too high-risk to do anything. Believing that nothing more could be done, the family asked how she would die. They were correctly informed that it would be a long and painful death, preceded by endless abdominal pain, eventual bowel infarction, subsequent peritonitis, and septic shock.
Distraught, the family called me with tears in their voices: “Doctor, isn’t there anything you can do?” I said: “sounds like Soylent Green medicine—bring me the films.” Bowel ischemia actually does quite well if even one of the three arteries is open. I felt confident we could angioplasty and stent the superior mesenteric artery quite easily, and told them so. I went through the risks, which of course were higher with her age and comorbid conditions. Despite this, neither the patient nor her family was ready for her to die a horribly painful and lingering death. Working quickly, but unable to break free from my own schedule, I had them go see my mentor at El Camino Hospital in Mountain View, California, with whom I had spent one to two days every month for five years, training in complex endovascular procedures during the early years of my private practice. After another lengthy consultation with him, detailing how risky it would be, they gratefully begged him to have the procedure performed. Carried out under local anesthesia in less than an hour, she was immediately pain-free and eating dinner like a horse that night. She and her family returned, eternally grateful.
Two months later I received a call. The patient was again doubled over in waves of intermittent abdominal pain. I felt it was much too early for stent restenosis and an abrupt occlusion would most certainly have presented with much more severe symptoms. Cautiously, I told them to go to the emergency room at another institution in the area. I called ahead and relayed her history to the physician on call. I gave instructions for a non-contrast CT and that if nothing was found, we would proceed immediately with direct angiography and possible intervention. I told him to treat her as if she were 60, not 95, years of age. The CT scan showed obvious diverticulitis and she responded well to bowel rest, intravenous fluids and antibiotics. She sheepishly admitted to knowing of her history of diverticulitis, but “just couldn’t resist those strawberries at brunch the other day.” With tears running down her cheeks, her daughter hugged me in thanks.
That night, the daughter and son-in-law asked if I would be in the office tomorrow, as they would like to take me to lunch as thanks. They met me after my last patient at one o’clock and we went out to lunch, where they explained to me how much joy the patient had and how full of life she had been since the procedure. She had put back on the weight she had lost and had a new zest for living. They thanked me profusely for making the difficult choice to go the extra mile for someone who was felt to be too high-risk to have anything done. They have since done some extraordinarily generous things for me as their way of saying ‘thanks again.’ I invited her and her family to our home for Christmas dinner and was amazed at how she energized and invigorated my own 96-year-old grandmother. That was now two years ago and the patient is still going like a fire-cracker.
All too often I see physicians trained to save lives imposing their own values on patients and their families, and simply giving up. The strong tendencies that now prevail in our country are to make sure that there is ‘dignity in dying’ and that dying patients are provided the utmost comfort in their passing. So much time, effort, and emotion is spent on trying to impress on patients and their families what a horrible experience it is to ‘have a garden hose shoved down your throat and have a gorilla pounding on your chest.’ The first question after admission is: “do you have an Advance Directive?” While I believe strongly in withdrawing futile care of an unsalvageable patient and have personally ‘pulled the plug’ on many a patient I have just worked heroically to resuscitate, only to find the patient had a Living Will and wanted no such treatment, I also believe the scales of mercy have tipped much too far in a most unfortunate direction—in effect euthanizing the most difficult to treat in favor of younger, more viable (and hence easier) patients. All too frequently, ‘no code’ is interpreted in practice to mean ‘no care.’
As physicians we have an obligation to make sure that our patients understand the risks, benefits, and alternatives to our therapies in as thorough, understandable, and complete a manner as possible. I was trained in the school of thought that if ‘after you have explained the procedure and the risks to the patient they still want to do it, you didn’t do a good enough job explaining it.’ That being said, just because a patient is a higher risk does not mean a course should not be taken; that decision needs to be made not by the physician with his or her own values of life and thereafter being imposed, but rather by patients and their families after being fully informed.
By the same token, I believe we have an obligation to look beyond our own abilities and experience and even outside our own community or State to find the solution to a difficult problem that we are personally unable to handle. I believe, whether because of our own egos and arrogance or simply lack of knowledge, we fail to offer some patients the only solution to correct their particular problem. Nowhere is this more apparent than in the treatment of the weak and elderly. Certainly, everyone would pull out all the stops to save a dying baby, a teenager, or a young adult. Most would do this for the middle-aged and early retired as well. Presented with an octogenarian or older, sadly the offers of options decline rapidly.
How dare physicians ‘play God’ with anyone’s life? Most—if not all—of us can tell when a situation is absolutely hopeless, but to simply tell a patient or a family that it is ‘too difficult’ or ‘too risky’ or that there is ‘too little of a chance to make it’ is not our prerogative, but that of patients and their families, who should be the decision-makers. They are the only ones really able to decide whether they are willing to accept the risks. I tell my patients that, as physicians, we are no more than ‘glorified bookies’—’always playing the odds.’ Sure, we call it fancy names like risk–benefit ratio, but it really is the same. We know the statistics and the patient, to whom we should be able to present the information needed for choosing the most appropriate therapeutic direction. It is up to us to be sure that both our patients and their families know the odds. Beyond that, it is our duty to let them make the fateful decision. I urge all physicians to examine closely their own souls when treating difficult, complex, and high-risk patients. You cannot fully know your patients’ values, motivations, expectations, and aspirations, or what they might be willing to live with in the event of an imperfect outcome. As always, inform the patient and their families of the situation. If you, your colleagues, and institution cannot handle the problem confronting your patient, find out who can. Look for alternatives, even those you might personally consider extreme strategies. Consult the medical literature, leading medical institutions, and the Internet. Do not give up on a patient whose problems exceed the capabilities and facilities available to you. In this, you will have earned the satisfaction of knowing that you simply ‘did the right thing.’