ICU and the Cost of Healthcare

A man who takes very little care of himself comes in with diabetic ketoacidosis - uncontrolled sugar levels causing severe electrolyte disturbances - and overwhelming sepsis - infection of the bloodstream. The source of his infection is obvious; he has the largest decubitus ulcer I've ever seen. Decubitus ulcers are one of those things (similar to a bowel regimen) that we never learn in the basic science years of medical school yet we see them all the time in our clinical years. They are pressure ulcers or bedsores that happen mostly in bedbound patients from sitting or lying on a bony prominence too long. This patient's decubitus ulcer must have been brewing for weeks; it was over a foot long, deep into the muscle, an awful nonhealing infection. It was clear that no one had been taking care of this gentleman's health for a long time. He was brought to the operating room to debride the wound and take out nonliving tissue, then transferred to the ICU for further management.

The patient has been in the intensive care unit for three weeks. Each day in ICU costs around $20,000 as a baseline. Furthermore, for much of the stay, he required a ventilator, multiple drips for his blood pressure, hourly glucose checks and insulin titration, an array of wide-spectrum antibiotics, and multiple operating room debridements. I wouldn't be surprised if the hospital bill is over a million dollars, and that won't count the rest of his stay, his long-term rehabilitation, and the home care he will need if he makes it out. I'm not even sure he will; the bacteria he is growing are highly resistant, he has an abysmal nutritional status, and he is unlikely to ever fully heal that decubitus ulcer.

I don't want to pass a judgment on this type of patient, but we see it all the time. These patients have no resources, ability, or willingness to care for themselves, and as a result, their disease progresses so far that they ring up million dollar bills for an outcome we find upsetting. Are these endeavors worthwhile? Are they cost-effective? It's easy to say on a population level or a policy level that this type of care is not sustainable, but how do you say that to the individual person dropped off in the emergency department?

The hope, I believe, is that universal health care will ameliorate this problem; since everyone will have access, we will hopefully see fewer disasters of neglect. But it still does not obviate the problem of economics; what makes sense? What is ethical? And what is practical?