I served as attending physician in the internal medicine intensive care unit for five years. During that period, I pondered two questions every night. The first question was: "Could there still be a cure?" Second, for those patients who could not be cured, would never leave their hospital beds, and only relied on life-sustaining apparatuses, my question was: "Is this what the patient wants? If I were the patient, would I want this kind of treatment?"

Here is the case of a patient I encountered: A demented 85-year-old man suffering from chronic obstructive pulmonary disease was admitted to the ICU with respiratory failure. Following treatment, his condition improved so that the ventilator could be disconnected and the breathing tube removed.Nevertheless, at best, the old man could manage when given supplemental oxygen but he would still be short of breath.I told the patient's family that based on his prognosis he would most likely have to remain hooked up to a ventilator permanently should he have to be intubated again in the event of another respiratory failure. I suggested that they consider signing a "Do Not Intubate" consent form. Since some of the family members approved while others disapproved, no one dared to sign the document.

Two months later, the old man had to be intubated again because of end-stage lung disease. He was hooked up to a ventilator and rolled into the intensive care unit. After three weeks, he was transferred to the respiratory care center. Another six weeks down the road, the patient was transferred again, this time to the respiratory care ward.

As expected, the patient had to be kept on the ventilator all the time. A year into the treatment, the family members all had regrets about having made the wrong decision at the time. The old man died another two and a half years later, finally escaping the ventilator and leaving hospital.

This is a true tragedy. Although the family has to take some blame, the National Health Insurance's fee for service system is an accomplice too.

Accomplice National Health Insurance

A senior physician told me this problem did virtually not exist before the National Health Insurance scheme was implemented. When a patient was admitted to the ICU back then, the family would make a decision three days later when receiving the hospital bill.

Presently, when a patient moves to the medical center's ICU, where he or she is cared for round the clock by specialist physicians and registered nurses, the patient only needs to pay one tenth of the costs, a little over NT$1,000 per day. If the patient transfers to an ordinary hospital room, he will have to pay more than NT$2,000 per day if hiring a fulltime caregiver.

If a patient meets the criteria for critical illness [health insurance] coverage, such as when he has used a ventilator for more than 21 days, has a critical illness, suffers from cancer and so on, then the patient's co-payment amount for the ICU becomes zero. In such cases, the patient only needs to pay for his diapers no matter how long he stays in the ICU.

The National Health Insurance spent more than NT$5 million on this old man. While the man stayed in the respiratory care ward, his family had to pay hospital fees worth NT$30,000 per month. Since the patient received a lifelong veteran's allowance of more than NT$20,000 from the government, the family thought their financial burden was still tolerable.

What I care about most is whether the old man was suffering. Did he weep because of his illness? I do not know. He was unable to express himself because he could not utter a sound due to the breathing tube, and his consciousness was clouded due to dementia.

Are patients like this old man weeping? Probably they are. Just imagine: You have had a breathing tube inserted down into the windpipe, are connected to a ventilator with all four limbs restrained to prevent you from pulling out the tube. The medical prognosis says that the probability of you getting off the ventilator and walking out the hospital alive is close to zero. You sob silently because you don't know when all this will be over, because the hospital will do everything in its power to keep your heart beating.

Translated from the Chinese by Susanne Ganz