Column: For elderly patients, ‘caveat emptor’

If a person is obese, unvaccinated and has underlying conditions, but is younger than 65, should an older patient needing life-saving technology be deselected from that treatment in favor of the former because of age?

If an 80-year-old person with COVID-19 in the ICU (intensive care unit) can medically benefit from a ventilator, according to his doctor, should it be taken from him or her, because a young person who has just come in needs it?

Professional judgment is an integral part of a doctor’s medical training. Decisions about life and death will, at some point, be faced by a critical-care doctor. After kidney dialysis machines became available in hospitals, a team of physicians had to decide in favor of or against their availability to patients with kidney failure until enough machines were manufactured and distributed. Those decisions were based on the doctors’ medical judgment.

Physicians do not shrink from such decisions. They are trained to face them. Taking those decisions out of their hands and giving them to a committee made up of third-party medical and non-medical personnel, which is what a COVID-19 “Triage Allocation Framework” calls for, is a departure from “First, do no harm,” the guiding rule of medical practice.

A protocol that removes the attending physician from decision-making about his or her patient overturns the standards that have guided medical care for centuries.

The guidelines for rationing treatment for COVID-19 patients adopted by Gov. David Ige assigns points to patients based on factors, including their “life years,” a medical term for those with presumably more years to live. A quantitative analysis of a patient may seem more scientific, but it sidelines the attending physician, who has the best qualitative judgment of the patient’s condition and gives the decision to an offsite committee.

The framework admits an age bias that the senior patient encounters more subtly in other medical novelties that reduce the cost of caring for seniors who drive up treatment costs.

When my elderly cousin fell and broke her ribs, a “palliative care” team insisted that she be denied surgery to reduce her pain. She was offloaded to a “rehab” facility. I intervened to return her to the full-service hospital. The palliative care team insisted she was ready to die, and die she did.

My 85-year-old husband is disabled, and to many, his “quality of life” appears minimal — but in fact, love, support and home care provide him with an optimal daily life.

When he is acutely ill, he goes to the hospital, and responds to appropriate treatment.

During a recent admission, a specialist decided to refer him to “palliative care” without our knowledge. The specialist told us “everybody has to die sometime.” Apparently, advanced age makes that “sometime” sooner.

Reducing hospitalizations is one goal of the Accountable Care Organization (ACO), a network of doctors who manage care to lower overall cost. In the ACO plan, Medicare patients choose their doctors but receive more “efficient” care. Older, sicker patients take more time and are more costly. Doctors are paid more or less based on patient utilization of services. The public knows little about how the level of care for elderly patients compares with standard medical treatment. However, the Triage Allocation Framework brazenly makes no attempt to hide its age bias.

Whom should the patient trust? Their doctor, who is constrained by points and guidelines? The medical care business model that rewards a doctor’s cost-efficient decisions? The government that accepts a COVID-19 protocol biased toward “life years”?

“First do no harm” has been replaced with “Caveat emptor,” “Let the (elderly patient) beware.”

Honolulu resident Jean E. Rosenfeld, Ph.D., is a retired historian of religions (and wife of a physician) who serves on a hospital committee.