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Sundays With Dave

On most Sundays I visit my friend, Dave, who is tethered to a large tank of oxygen in his home as a result of being diagnosed with pulmonary fibrosis. Doctors give him one year to live.

Bad luck runs in streaks, it seems. Dave's diagnosis came on the heels of triple bypass surgery. In the process, he apparently picked up Parkinson's Disease. Dave's professional career was surveying, and he thinks the years of working outdoors and kicking up the desert dust for big time real estate developers finally caught up with him.

"I can't complain," Dave says philosophically. "It's not like I didn't have a life."

I look forward to seeing Dave. We talk about things that matter. It's like church, only without the dogma. Dave and I share an interest in Zen and an appetite for uncertainty. Is there a God? Who knows? It's more fun not knowing. There is always something to discover, something to learn. Certainty is the real killer in the world today.

Dave says he's going to be really pissed if he dies and finds himself someplace else. He can't imagine being anywhere else but here.

Dave's future may be looking up. His daughter refused to accept his physician's grim assessment and found a lung transplant program in California that happens to have a short waiting list. Dave is over there right now, getting checked out to see if he is a good candidate.

What makes this interesting is that Dave, an ex-Marine, is a patient in the VA, and the VA doesn't provide lung transplants to patients over 65. But Medicare does. Dave is 67, and if he goes through with it, Medicare will most likely pick up some of the tab.

It's not cheap. The average cost of a lung transplant these days is around $250,000, and that doesn't include the pre-transplant work and the follow up of approximately $40,000 annually. Even then, the chances of surviving beyond five years are roughly 50 percent.

Although they won't pay for his transplant, Dave loves the VA. "Best care I've ever had," he tells me. "Great doctors, great system, it's all electronic. It's perfectly sane not to do lung transplants for people over 65. You can't do everything for all the people all the time. The system would go broke."

Which, of course, it is.

But determining what is rational and cost effective, and wanting to live, if only for another five years, are two different things. It's interesting to observe that it was Dave's family that initially pushed the transplant, not Dave himself. It reminds me of a story recently told to me by a young internist, who routinely checks in on a 90-year-old patient on life support in an ICU.

"Basically, she's dead," he says. "But her family won't let her go. They keep hoping for a miracle. It's ridiculous. The woman is 90, for God's sake. No wonder the system is going broke."

Dave and I talk openly about all this. He knows the score, the odds on him living much longer, the reasons for rationing care for people in his situation. I tell him about esoteric health policy stuff like quality-adjusted life years, why we need to find a better way of rationing care, especially end-of-life care, than we do now, and the perverse financial incentives doctors and hospitals have to keep people alive way beyond the boundaries of good health and common sense.

Dave concurs. He is a smart, sensitive guy. "I'm not afraid to die," he tells me. "But all things being equal, I'd rather live, even if it's only for another few years. If I've got a shot, I'm going to take it."

Exactly. And I'm going to be in his corner, pulling for him.

Sundays with Dave remind me of our common humanity and frailty, and the ludicrousness of the simplistic view that health is a commodity, we are merely consumers, and we can leave decisions of life and death to so-called free markets.

The future is provisional. Let us first minister to and comfort each other. The ethical heavy lifting will be upon us in due course.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.