Seminars in Nephrology - Editorials (1981-1988)

The Debate Over Medical Costs

The cost of the End-Stage Renal Disease (ESRD) program has attracted much attention in the lay press. The thrust of this coverage has been at the one billion dollars spent to keep 50,000 patients alive. The recent report that more than 40% of ESRD patients are incapable of a level of physical activity beyond that of caring for themselves has brought further public scrutiny to the program.

This issue is a major one and deserves extensive debate. Inimical to such a discussion is the dismal state of most medical reporting. When contemplating medical coverage by the media I am reminded of George Bernard Shaw’s comments about the state of music criticism in late 19th century England. Editors were so unconcerned with the subject that they assigned people with no background in the field to cover it and made no effort to check if their reports were accurate or verified.

Similarly, most medical reporting makes use of information printed in medical journals with no attempt at critical review of the content. Even more serious is the tendency to interview one “expert” and then present his views without either critical review or resort to another source. Such reportorial techniques would never be tolerated by the political or international editor.

If the issue of the cost of the ESRD program is to be understood it must be placed within the entire context of modern medical care. A series of important questions must be answered – as things now stand they have not even been asked.

What do the people most involved think? One has only to look at the outrage that greeted the recent suggestion that the food stamp program be reduced to imagine the reaction to the decision to let poor people with chronic renal disease die while those able to pay for dialysis live. Noteworthy about the study of the quality of life of patients on dialysis is that it was based entirely in physicians’ assessments. No one asked the patients what they thought. My impression is that almost all of them prefer treatment to death.

What about other expensive health programs? ESRD consumes only a small part of the health dollar. Despite incessant propaganda to the contrary, almost no progress has been made towards a cure of cancer. Indeed, Seldin has said “the conquest of cancer is a laudable social goal, but its realization on the basis of present theoretical knowledge would be akin to charging pre-Newtonian physics with the responsibility of designing and fabricating an atom reactor.” The most recent data available from the National Cancer Institute show no decline in cancer deaths over the past 50 yr. I have yet to see anyone suggest that we curtail cancer therapy since it is cost ineffective. One cannot, however, meaningfully discuss the ESRD program without including this issue.

What about coronary artery bypass surgery? Its effectiveness is hotly debated. What about geriatric medicine? Why spend billions of dollars on older people whose likelihood of rehabilitation decreases with every day? Most internists spend a major portion of their time caring for people who have diseases with little hope of rehabilitation. I offer no opinion how these issues should be decided, only the hope that they be debated in the context of the entire problem of dealing with chronic disease in an aging population.

The decision as to whether to curtail funding for the treatment of ESRD should not be an isolated one. It should be made as part of an evaluation of the desirability of spending large sums on the management of all chronic diseases for which there is no cure available. In other words, if no coordinated health planning develops in this country (a development as likely as finding a cure for cancer this year) decisions concerning the allocation of resources for medical treatment will be made the same way those regarding the construction of dams and other pork barrel projects are made. Lobby will be pitted against lobby. A full public debate of health expenditure is mandatory if intelligent decisions are to be made. A future issue of Seminars in Nephrology will examine the ESRD program against this background.

REFERENCES:

1. Gutman RA, Stead WW, Robinson RR: Physical activity and employment status of patients on maintenance dialysis. N Engl J Med 304:309-313, 1981

2. Seldin DW : Specialization as scientific advancement and overspecialization as social distortion. Clin Res 24:245-248, 1976

3. Ca 31:18-19, 1981

Neil A Kurtzman, MD

A New Medical Service

A long with the demise of many of the outlandish ideas of the late 1960s that so entranced some of our best thinkers, concern for the state of the medical record has died a peaceful death. In our hospital the problem-oriented record has ceased to be a problem since reduced to a single page of yellow paper somewhere near the top of the chart, which within two days of the patient’s admission, resembles any exposed surface in New York City. Those members of the faculty that talk about patient records again do so with the reticence that once was reserved for the discussion of one’s sex life. Nevertheless, the patient’s chart will not go away. That is unless you want it.

At most of the hospitals I have familiarity with, the Record Department seems to exist for the sole purpose of losing the chart. An endless line of patients seems to be entering our hospitals from the outpatient clinic without outpatient records. Or, the patient is readmitted but his record of previous hospitalization is not. Why we can find our patients but not their charts is a great unanswered question.

Two solutions come to mind. The first is to close the record room and throw the charts away as soon as they reach a certain bulk. (Of course they may be lost before reaching critical weight, but that would be all to the good.)

The second solution has the virtue (or drawback) of optimism. It attempts to regularly review the patient’s chart. Close the record room and give the patient’s chart to the patient. He can lose it for less money than can the record room. Since he can regularly find his way back and forth from the hospital and/or outpatient clinic he might do so with his chart.

Having solved the problem of the lost chart, we must now face the problem of what to do with it when we have it. One of the problems of decreeing that everybody who works in the hospital is a “professional” is that everybody wants to write in the chart. I have no doubt that before long the elevator operators will be writing regular notes in every chart. As a result of this institutional prolixity the average medical chart soon reaches Proustian dimensions. Consequently, nobody reads the chart.

There is no doubt that useful information occasionally finds its way into the chart. Gresham’s law operates here as in economics. Bad information drives out good — or at least completely obscures it. There needs to be some way that useful information can be extracted from the compacted effluvia that constitutes a typical medical chart.

The solution, in my view, to this problem is to form a new service — the Chart Reading Service. When confronted by a large and complicated medical record, the attending physician can consult this service. The physician (from the Chart Reading Service) who answers this consultation will carefully read the chart and write a brief note outlining the pertinent information contained in it. This note will never exceed 200 words.

In addition, new chart racks can be designed that automatically weigh the chart and send in a consultation to the Chart Reading Service when the weight of the chart, exclusive of the chart holder, exceeds one pound.

I can envision the proliferation of this service to all hospitals and even to doctors’ offices. Fellowships in Chart Reading soon will be offered. The American Board of Chart Reading will be established and give biannual certifying examinations. In due time, a committee of program directors of Chart Reading Services will convene a meeting that will establish a uniform acceptance date for applicants for fellowships in Chart Reading.

Finally, Medicare, Medicaid, and other third party payers will establish a ‘‘reasonable’’ charge for this service. The payment for Chart Reading will of course require a note in the chart (this allows for an infinity of chart reading opportunities) signed or countersigned by an Attending Physician. The fee will be based on the weight of the chart read, about $150/pound seems right. Follow-up visits will be less.

When in doubt, expand.

Originally Published:

Kurtzman NA (ed): A new medical service. Sem Nephrol 1:209, 1981.

Electronic records may help some. While you can lead a doctor to a computer, you can’t make him read. Some medical specialties are doable without any reading skills.

NK Dec 2007

Everything’s Got a Moral, If Only You Can Find It

In moments of weakness, when I should be doing something useful, I sometimes think about the logic that underlies the way medicine is organized (disorganized is probably a better word). The business—and it is a business, what with consumers, advertisements, and reimbursement rates—seems to thrive on contradictions. Consider medical care for the indigent; if you do so, you are apt to be lonely, but do it anyway. In Illinois, as in many other states, the recession has caused the state to drastically curtail the amount of money available to support health care for the poor. Consequently, many impecunious but honest citizens are denied necessary medical care. Dishonest citizens, however, appear to have an ironclad legal right to every form of medical care.

Convicts have a right to medical care, enforced by numerous court decisions, which is absolute, if you are seriously in need of medical care and are without resources, a logical step is to commit a crime. Of course, you must make sure that you get caught and that your lawyer is a complete nitwit. Otherwise, you probably will not be sent to jail. To ensure a jail sentence, you should commit a serious crime and insist on your sanity. Once you have garnered a jail sentence, the state will provide you with whatever medical care you require or think you require.

Suppose you are not a citizen but are an illegal alien. The state will assume no responsibility for your medical care even in times of plenty. In the unlikely event that you are apprehended by the immigration authorities, you may even be deported if it is politically expedient to do so. Again, however, crime pays. Get yourself into jail, observe all the mechanics mentioned above, avoid deportation, and once again the state will assume complete responsibility for your medical needs.

Not only will the state provide medical care for convicts, but inmates of penal institutions have the right to bring suit in federal court alleging that the care they receive is substandard. If they succeed in convincing the court that only one of however many charges of ill treatment they allege is correct, then the state must pay their entire legal bill. It should not be necessary to comment on how frequently the state pays for the services of a high-priced lawyer engaged by the poor but honest soul.

Leaving the dark world of incarceration behind, one can find similar contradictions in the well-lit offices of hospital administration. In an office with a potted plant or two, false ceilings, fluorescent lights, and a pleasant outside view, one is apt to find a hospital administrator who on Mondays, Wednesdays, and Fridays writes memos to the physician staff in his capacity of director of the PSRO program, asking them to justify the need for hospitalization of patients who fall under the purview of this exotic program. On Tuesdays and Thursdays (Saturdays these offices are dark), in his capacity as a high-ranking hospital administrator, he writes letters to the chiefs of services imploring them to fill the empty beds which are becoming an increasing embarrassment to our overbuilt hospitals.

In another part of the hospital sits a wise physician who bores his residents and students with daily admonitions to decrease the cost of medical care by ordering fewer
sophisticated diagnostic procedures which jack up the hospital bill. In his philosophical
ruminations, he elevates the physical examination to the level of the deity while
consigning the CT scanner to the underworld. In his private practice he orders every test available to protect himself from the omnipresent clutches of the malpractice lawyer.

In yet another office, the chief of staff imposes a set of rules governing the “do not resuscitate” order. These rules, while not understood by anybody, induce a state of near total paralysis on the part of the nursing staff which eventually is cured by resuscitating anything that remains motionless for more than five minutes. Across the street a medical ethicist writes about death with dignity, removed from the sound of breaking ribs.

Since we all want to be nice, we come up with nice rules. Since abortion is intensely controversial, it seems reasonable to permit those hospital personnel whose convictions do not permit abortion to refrain from taking part in this procedure. The logical continuation of this practice is to permit other hospital employees to opt out from these procedures which they find personally repugnant. For example, a Jehovah’s Witness who happens to be a hospital transporter should not be required to carry blood from the blood bank to the bedside. Ultimately, one can imagine Christian Scientist pharmacists and physicians who dispense no drugs and perform no surgery. Carried one step further, we arrive at the personnel department’s beau ideal: a different job description for every employee, written by each employee.

One should never forget the maxim of the great, but unknown, pre-Confucian philosopher: “The examined life is not worth living.”

Originally published:

Kurtzman NA: Everything’s Got a Moral, If Only You Can Find It. Sem Nephrol 3:167, 1983.

Metaauthorship

Physicians like to be successful. Not just financially, they like to do what they say they’re going to do. This is why the annual release of the cancer mortality statistics proves so discouraging to all but the most giddy optimists, ie, oncologists.(1) It is also why doctors venture into distant territory; they seek success. If you can’t cure cancer, maybe you can attack an easier target and thus get better results. The prevention of nuclear war is a laudable social goal. It doesn’t seem to have much to do with medicine more than with anything else, but physicians band together to prevent it, arguing that the world’s health will be bearish after a nuclear war. No one can deny that, just as no one can deny that the cement industry will crack or that chicken farmers will be in deep you know what if the world blows up.

All these niggling quibbles notwithstanding, we haven’t had any nuclear wars since doctors decided to prevent them. Success is success. It’s a weekly column in one of the world’s leading medical journals. It’s a Nobel Prize. And you don’t even have to take night call. There is a world full of opportunities out there for frustrated doctors who are tired of trying to capture the entire gross national product for the diagnosis and treatment of untreatable diseases.

While I’m going to keep most of the good ones to myself I’ll give one away—Physicians Against California Breaking Off and Falling Into the Pacific Ocean. Think of all those potentially soggy west coast HMOs and of the high likelihood of success, at least for the short haul—all of which brings me inevitably to multiple authorship on medical papers.

I’ve written about multiple authorship before, never dreaming that anyone would really do anything about it.(2) It didn’t seem to offer the boffo opportunities innate in thermonuclear catastrophe or the San Andreas fault, but lurking in the “Uniform requirements for manuscripts submitted to biomedical journals” (a document that will be read in its entirety only by those with a truly empty calendar) is a brief section on authorship that appears as well thought out as the imposition of SI units on the medical laboratory.(3)

Consider this: “Authorship should be based only on substantial contributions to (a) conception and design, or analysis and interpretation of data; (b) drafting the article or revising it critically for important intellectual content; and on (c) final approval of the version to be published. “Conditions (a). (b). and (c) must all be met” (italics mine).(3)

Think about what this means. Suppose you’ve done some work with a fellow or a medical student and get around to publishing it with your usual deliberate speed and the journal you send it to reviews it with its customary dispatch; the fellow may be retired and the student is sure to be in practice. You’ve got to find them to get their final approval. If the student hasn’t graduated, he’ll probably be on a psychiatry elective in Ceylon trying to figure out why it’s now called Sri Lanka. One fellow will be back in Peru dodging the Sendero Luminoso, and thus impossible to locate, while another will have returned to France and will be refusing to speak English. So who will sign the copyright transfer form—yourself and three secretaries. But that’s not honest and “The issue is honesty.” That’s what the Journal of Laboratory and Clinical Medicine says in a brief but pious editorial.(4)

The honest alternative is to follow the rules and not publish anything you didn’t do all by yourself or with your Siamese twin or not to publish anything. On slight reflection the latter course doesn’t seem so bad, but a cessation of weekly ruminations on global incineration or ecologic calamity would force many of us to stagger back to patient care unable to prevent nuclear Armageddon or to give the Golden State a seismic vaccination. Not only would everyone miss our important intervention into the course of human events, but all this extra patient care would give the economy an enema that it needs as much as does a patient with cholera.

Finally, contemplate the requirement “for important intellectual content.” Most journals would be empty advertisement sandwiches if this one were enforced. Okay, your work is a vast Jupiter of intellectual content; but suppose you did it with a surgical colleague. Where does that leave him? Your brain may have conceived a grand design, but his hands made it possible. The new guidelines (rules?) indicate that he merits an acknowledgment at best. It would be interesting to observe his reaction when you tell him this. I mentioned above that these requirements seemed about as well thought out as SI units. When I looked at who had actually written them I discovered to my shock and amazement that they were largely the same. If I were good at finding morals I’d probably find one here.(5)

References:

1. American Cancer Society: Cancer Statistics, 1988. CA Vol 38, No 1, 1988

2. Kurtzman NA: Important trends in medical journalism (ed). Semin Nephrol 4:193, 1984

3. International Committee of Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical journals. Br Med J 296:401, 1988

4. Daniel TM: Authorship: The International Committee of Medical Journal Editors offers guidelines (ed). J Lab Clin Med 112: 137, 1988

5. Kurtzman NA: Everything has a moral if only you can find it (ed). Semin Nephrol 3:167, 1983

Originally published:

Kurtzman NA (ed): Metaauthorship. Sem Nephrol 8:315-316, 1988.

Seminars in Nephrology Does Not Switch to SI Units

You may not have noticed if, like a sensible person, you do not read editorials, that there is an attempt to convince (more like coerce) medical writers, and more ominously, laboratory directors to report results in SI units. “SI units” is the abbreviation for Le Systeme internationale d’Unites. This is enough to tell you that we are in deep trouble.

An outgrowth of the metric system, SI has been widely used throughout the world, we are assured (see the reference), but has had little impact in the United States, even though Congress passed the Metric Conversion Act in 1975. I suppose this is the reason that medical science in this country lags so far behind the rest of the world. I also am sure that you remember the Metric Conversion Act of 1975 and that you buy your gasoline by the liter.

The move to SI seems to have been initiated by the American National Metric Council, an organization I am not familiar with, but which seems to be a spiritual kindred of the Universal Esperanto Association. It also seems to inspire great zeal for its cause in its members. Since any change is difficult, there should be a good reason for adopting it, especially one that requires blood gases to be reported in pascals (everyone knows that a pascal is a kg.m-1.s-2). What might it or they be? The ANMC seems to feel that medicine needs a coherent system of units so that there may be effective interchange of information between nations and disciplines. They present no evidence that there is a communication gap resulting from incomprehensible units or that, if such an information gap exists, SI will help. The whole business seems to be presented as a matter of faith. It is ironic that a system advocated by scientists should be put in place in the name of science without its partisans feeling any need for scientific rigor.

Doubtless my failure to grasp the urgency or even the slightest need to switch to SI units represents a personal inability to see the big picture, but the system seems cumbersome, confusing, inconsistent, and unnecessary. SI uses the familiar pascal as the unit of pressure, but magnanimously allows the use of mm Hg for blood pressure, though not for blood gases. I’m sure you can already see how SI is going to simplify your life. Another great concession by the ANMC is their permission of the use of the unit “day” even though it is not an SI unit. Without this dispensation you would have to express urinary protein excretion in grams (I think it’s alright to use grams) per 86,400 seconds.

I hope you realize the seriousness with which this business is approached by those who spend a major portion of their time contemplating the proper application of the SI system. The implications of the system are dissected with talmudic precision. Consider the following:

“Although much debate has centered on the reporting of hemoglobin concentrations with mass concentration (g/L) as well as substance concentration with both the monomer, Hb (Fe), and tetramer, Hb (4Fe), being advocated at different times, the International Committee for Standardization in Hematology indicates greater support for expressing hemoglobin as substance concentration in terms of the monomer. At least for the present, the Medical and Health Coordinating Group recommends continued use of mass measurement of hemoglobin concentrations, so the reporting unit is g/L.”

The quality of the prose aside, one recalls Henry Kissinger’s dictum that academic disputes are so bitter because the stakes are so small.

The SI system that is designed to simplify clinical measurements sometimes becomes so complex that new units have to be invented. Enzyme activity is no longer to be expressed as international units per liter. The SI system’s official unit is mol.s-1.L-1 which it feels, with reason, is difficult to write and difficult for a computer to print. The unit katal (at first I thought these were African cows), abbreviated kat, corresponding to mol/s has been proposed as a special name to report catalytic activity. What we end up with is kat/L. Thus, an abbreviation for a new unit to replace an official unit in place of the old unit is established by Le Systeme internationale d‘Unites. To paraphrase Yossarian, that’s some system that Systeme Internationale.

Don’t be surprised if one day you pick up a lab slip and find that you don’t understand a single value on it. What probably will have happened is that a mole from the ANMC has infiltrated your clinical lab and surreptitiously reprogrammed its computers to SI units. Now you’ll discover that every patient you see requires a clinical pathology consultation to interpret his lab data. Please, how many mm of Hg to a pascal?

What will happen? Not much, I suppose. When European journals switched to SI units many American authors continued to use the units they’d always employed when they sent a paper abroad, with little consequence to its ultimate acceptability. Much to the relief of your secretary, good old American sloth and passive aggressiveness will probably rescue us once more, this time from the Babelian angst of the ANMC. The French, who started this whole thing, have also provided the solution – Vive l‘indifference!

Reference:

1. Young DS: Implementation of SI units for clinical laboratory data: Style specifications and conversion tables. Ann Intern Med 106:114-129, 1987

Originally published:

Kurtzman NA (ed): Seminars in Nephrology does not switch to SI units. Sem Nephrol:

7:171-172, 1987.

Seminars in Nephrology

VOL. V, NO. 3 SEPTEMBER 1985

Financing Fellowship Training

Walter Lacquer, a penetrating scholar of German history and politics, feels that one of the most distinctive characteristics of the German people is a tendency to too much. This appears to be a trait not limited to Teutons. With respect to medicine, we seem to have too little or too much care, too few or too many doctors. The same people, or their clones, who 20 years ago decried the shortage of physicians now have dis­covered that we are up to our endoscopes in doc­tors. This realization is likely to have interesting effects on the training of nephrologists.

Senators Dole, Durenberger, and Bentsen have just introduced an amendment (S. 1158) to the So­cial Security Act which, if passed, will have a pro­found effect on the funding of all graduate medical education. Among the bill’s provisions are a limit on the number of years of residency training that Medicare will support and an end to the funding of training of alien (excluding Canadian) graduates of foreign medical schools.

The bill would provide a maximum of five years of residency training, but no more than the mini­mum number of years necessary to satisfy initial Board eligibility. In other words, three years for a medical resident and five for a prospective sur­geon. The thinking of the senators is instructive and not entirely logical. (By the logic of politics, it is totally coherent.) The following quotations are all from the Congressional Record of May 16, 1985, beginning page S 6337:

Open-ended funding of medical education cannot continue.

The contraction of subspecialty slots likely to result should shift emphasis more to Primary care training. In this way, more physicians in training will choose to end their graduate medi­cal training at the still-needed first contact spe­cialties.

It does not appear to continue to make sense to use Medicare Trust Fund dollars to underwrite AFMG (alien foreign medical graduate) train­ing. The aliens who train here frequently plan to stay and ultimately also contribute to this na­tion’s over supply of physicians.

Though I (Bentsen) am pleased to be an origi­nal cosponsor of the pending bill, I am not yet satisfied that the question of funding graduate fellowships has been properly addressed, partic­ularly as it relates to internal medicine residen­cies.

Many might agree that it does not make a lot of sense to have graduate medical education open ended. S.1158 proposes to address the problem by training less specialists and more primary care physicians. What it does, however, is support the training of urologists at the expense of nephrolo­gists, of orthopedic surgeons in preference to rheumatologists. This anomaly results from the different board structure of surgical and medical subspecialties: a single board in the case of urol­ogy; two boards in that of nephrology. The bill will support training only to the point where a trainee is first able to sit for a board examination.

The Association of Professors of Medicine has recommended the compromise of funding a fourth (but not a fifth) year of training in internal medi­cine. This proposal is, of course, an admission of insecurity because it still leaves intact the inequal­ity between medical and surgical specialties. The Professors feel that one year is all they can hope for and that one is better than two. Their logic is as impeccable as their standing with the Congress is weak. Why our position with our legislators is so fragile is not clear. Senator Bentsen, at least, ap­pears to be aware of the inherent unfairness of the proposal.

The issue of foreign medical graduates is sheer politics. Aliens do not vote. American graduates of foreign medical schools do, and so do their families. Therefore, the senate is unwilling to fund alien graduates of foreign medical schools while it is content to support American graduates of the same institutions. The concern of our solons about open-ended subsidies is nowhere to be seen on this issue. Foreign medical schools can accommodate as many of our citizens as they can squeeze in, and the federal government will subsidize their gradu­ate education. In effect, this bill cedes to institu­tions beyond our jurisdiction the right to determine how many residency slots the government will un­derwrite.

Of course, the bill is not yet law. It still may not be when this appears. There still is time to present arguments for its modification. Two reasonable changes are to treat medical and surgical residents the same and to limit the number of foreign gradu­ates, regardless of citizenship, we will subsidize. We could change our board structure to match that of surgery and perhaps obtain funding for fourth and fifth year residents, but that would be a law­yer’s trick and not an educationally sound reason for modifying what has proved to be a satisfactory system of certification.

Finally, why the preference for Canadians over Mexicans? Canadian graduates of Canadian schools who take residency training in the United States will continue to be supported by Medicare, whereas Mexicans will not. Surely, it cannot be because the Senate thinks Canadian schools are better than Mexican. If that were so, they would not be willing to fund American graduates of Mexican medical schools.

Originally published:

Kurtzman NA (ed): Financing fellowship training. Sem Nephrol 5:155-156, 1985.

The Ultimate Problem

Mr. Lincoln (not his name) was a 54-year-old man with metastatic prostatic can¬cer and chronic renal failure. He had been on dialysis for a number of years and, for a while, had done well. When the diagnosis of metastatic prostatic carcinoma was made, he underwent a bi¬lateral orchiectomy. He refused chemotherapy, however. For a while, he continued to do well de¬spite the obvious presence of cancer. Another hos¬pitalization was required to treat congestive heart failure. During this time the patient lost 30 lb of edema as a result of vigorous dialysis therapy. He had some pain from his tumor, but in general was reasonably comfortable.
Two weeks after his discharge he was readmitted because of abdominal pain. His tumor mass had obviously enlarged. In addition, he had developed an abdominal wound which appeared to be drain¬ing feces. Further evaluation demonstrated a fis¬tula between the rectum, the bladder, and the skin. Medical oncology was consulted but felt there was no effective treatment they could offer this man. The patient, who was highly intelligent and in complete possession of all his faculties at all times, was apprised of his situation. He understood that he had an untreatable cancer and that all we could offer was relief of pain. We asked if he would be happier if he were discharged from the hospital with an appropriate prescription for pain relief. He stated that he would prefer to remain in the hospi¬tal. We readily agreed to this and then discussed the matter of continuing his dialysis treatment. We told him that, if he wished, we would continue to dialyze him as vigorously as we had in the past, but that if he felt such treatment would only allow him to die a painful death (with the passage of each day his pain became progressively severe) we would stop dialyzing him. We further explained to him that he could take as much time as he wished in making a decision and that regardless of the de¬cision he made he could change his mind. He in¬quired as to how long we thought he would live and in what condition if we continued dialysis and asked the same information if we were to discon¬tinue this treatment. We gave him our best estimate while explaining that it contained a considerable margin of error.
He thought about his options for about five days, and then told us on rounds that he thought he would prefer to stop dialysis. We told him again that if at any time he changed his mind we would restart his artificial kidney treatment. He said he understood this and thanked us for our concern.
Mr. Lincoln, who was a very proud man, had three children who were very fond of him. Despite this he had avoided them during this terminal phase of his illness. While never expressed, we felt that it was his desire not to be a burden on his family. From talking to his children, it was quite obvious that they did not consider him a burden and wished to spend more time with him. We asked him if he would mind if we called them and informed them of his decision to stop dialysis. He said he had no objection. We called his children and they immediately came to the hospital.
During the last few weeks of his life, Mr. Lin¬coln had formed an especially close relationship with one of the medical students on my service. He told the student that he would like to have a beer with him. He also expressed a wish to have a bowl of coconut ice cream. The student obtained the ice cream and two cans of beer and they spent part of a Saturday afternoon together drinking the beer, eat¬ing the ice cream, and talking. Mr. Lincoln’s daughter was in the hospital that day and asked if she could spend the night with her father. This was arranged and she slept in his room that night. During the evening, the house staff asked Mr. Lin¬coln if there was anything that he would like to have. He said that he would really enjoy a glass of orange juice. This was obtained and he drank it with relish. Shortly thereafter, he went to sleep with his daughter in the room. At 6:00 in the morning the nurses noted that he was dead. It had been three days since his last dialysis. On Saturday morning, his serum potassium was 6.7 mEq/1. While we can’t be certain, it seems highly likely that Mr. Lincoln died from the cardiac effects of hyperkalemia. The source of the excess potas¬sium, of course, was dietary.
In thinking about Mr. Lincoln, a number of questions keep recurring. I have the answers to none of them, but they are important questions nonetheless. Did Mr. Lincoln die as the result of euthanasia? Did he commit suicide? Did he die from natural causes? Clearly, if he had not stopped dialysis and had not consumed foods high in potas¬sium he would not have died when he did. As I have said, he was highly intelligent, and while we did not discuss this, I have no doubt that he was aware that orange juice is high in potassium. I know we were also aware, though we were not thinking about that when we gave him the juice. If we had given him potassium intravenously, that clearly would have been euthanasia. How different is it to give him food and drink high in potassium when he had no renal function and was not receiv¬ing dialysis treatment? Giving him cyanide by mouth would have been legally and morally wrong, but giving him dietary potassium seems to be all right.
Last, given that Mr. Lincoln had untreatable cancer, he was in a sense fortunate to have chronic renal failure. He had the option to stop dialysis and die peacefully and at a time of his choosing. If he had had metastic carcinoma without chronic renal failure, his death would have taken a considerably longer time and been associated with much more pain than he experienced. Regardless of his wishes, we would have only been able to treat his pain while waiting for his disease to kill him. The problems I am raising are as obvious as their solu¬tions are elusive. We can relieve pain and suf¬fering, but only to a point. The patient can, in es¬sence, take his own life when he has widespread cancer if he is fortunate enough to have a disease like chronic renal failure. He cannot take it by a more active course. I cannot even begin to compe¬tently discuss a problem which has troubled theologians and philosophers for centuries. But the distinctions between what is permissible and what is not sometimes appear precious. All I do know with certainty is that we helped Mr. Lincoln and that he knew we were helping him and was grate¬ful for our efforts. I feel good about the way things worked out.

Originally published:
Kurtzman NA: The Ultimate Problem. Sem Nephrol 3:75, 1983.