The Gate Keepers of Death, by David Glenn Cox

There are several reasons that I believe we won’t get adequate healthcare reform. The first reason is that we don’t really deserve it. We let the political class ride unicycles and juggle bowling pins, anything to amuse the cows. Then we let the media and special interest lobbying groups tell us what’s good for us and what’s bad for us. We rail against what we don’t like and mumble about what we do want, and since the bulk of us are healthy it is just a quiet murmur instead of the torch-bearing, angry mob that it should be.

Any impartial review of America’s for-profit healthcare system would find it to be the most unsuccessful endeavor since the tower of Babel. They try to save the dying while they ignore the sick. It is intentional and criminal, but it is easier to bill an estate because dead men argue no invoice. It has been said that the largest amount spent on health care is spent in the last six months of life. We’ll spend half a million dollars to cut, probe, prod and pry every orifice of an eighty-nine year old to try to goose them along to eighty-nine and a half.

I spent a short time working as a representative for an ambulance company. My job was to call on nursing homes and to convince them to use us as their primary carrier. The competition for business was fierce and the pay lucrative. One sunny spring morning I strolled into a nursing home. There was an elderly man sitting in the sunshine outside the front door. Trying to be friendly I asked, “How are you this morning?”

“I’m old, damn it; how the hell do you think I am?” But I didn’t let him rain on my parade any. He was at least mobile and lucid, as inside, down long corridors, were the rooms of the deteriorating elderly.

They lived two to a hospital-room sized coffin, hooked up to drips and monitors, in diapers and hospital gowns, each with a TV blaring. I was struck by the absurdity of the blaring TVs because many were not lucid, and even for the others the TV had no relevance to their lives whatsoever. Wheel of Fortune or Entertainment Tonight? As absurd as using vitamin water to waterboard prisoners in Guantanomo; perhaps it was a comfort but probably not. It was a comfort for one and all to exclaim, “See? They are not left alone; they have TV!” I began to understand the man at the door.

Calling on a nursing home wasn’t much different from calling on auto parts stores. There’s some people checking the inventory, along with billing clerks and warehouse people. You bring them candy or gift baskets and put your stickers on the phones, then leave your card in the head nurse’s office. They’ve got to like you for you to have a chance with them, so you’ve got to make nice. But it was difficult for me to do because I didn’t feel comfortable in a warehouse of the dead but still breathing. I left the candy and made small talk but always felt ill at ease.

This was a mid-range warehouse. I had called on some that were nicer, and some that were worse. I’ve had paramedics tell me tales of the truly awful ones where they wrapped the dead in electric blankets so they could say that they had only been dead an hour when it was more like three. The nicer ones had flowers on the desk and nice wallpaper and drapes. Some had aviaries full of colorful finches. but once past the facade the game was the same. Poor wretches, frozen in contorted positions, waiting for the reaper and always with that confounded TV on.

As I came into work one morning the boss called me into the office. “Look,” he said, “I’ve got two people who have called in sick today and I’ve got a full schedule of totes. Can you do me a favor and drive the Med-van?” Trying to be cooperative but at the same time fully apprehensive, I explained, “I don’t mind driving but I feel very nervous because all your people have medical training and I have none.”

We picked up our first patient at the nursing home. She was an elderly woman who couldn’t have weighed over ninety pounds. She lay on the bed motionless and expressionless; she never made a sound as the nurses and I lifted her by her sheet onto the gurney. I had driven the ambulances before, shuttling them for repairs or to fill them up with gas, but this was my first time with human cargo. We carried her twelve miles to the doctor’s office, a palatial palace of a building with electric doors and a tall, wide atrium. We wheeled her into the foyer and the medic went to the front desk to get instructions.

We were told to leave her there and they would take her back later while we returned to the ambulance. Or next run had been canceled so we were told to just wait there. We waited for forty-five minutes as the old woman lay on display in the middle of the foyer on a gurney, in a dressing gown, covered with a sheet. Finally they took her to the back; she was in and out in twenty minutes and then we drove her back to her bed in the warehouse. We charged $95.00 each way or $190.00 for a twenty-four mile ride. The doctor charged considerably more, and Medicaid paid for it all.

My heart went out to her because of the indignity of it all, the callousness to be left on the floor like a freight delivery. If common sense ruled the day the doctor should have come to her. We didn’t deliver her for treatment, but merely for a card punch. Cha ching, easy money! The doctor wins, the ambulance company wins and the only one shorted and inconvenienced is the patient. It wasn’t for treatment, only to check vital signs to measure the sand left in the hourglass. It was five o’clock when we got back so it was my last run, but I told the boss that it really upset me to drive in traffic with someone that frail.

The truth was it upset me to tote people who didn’t need to be toted. Years ago I spent three days installing an acoustical ceiling in a funeral home and it didn’t bother me near as much because those peoples’ troubles were over. Here I felt like I was part the antagonist and part of a truly awful system and I could sell it but I couldn’t perform it.

My father’s family has two known traits, alcoholism and colon cancer. The first is so strong that it’s made me believe that my family were indeed the original creators of the alcoholic beverage. In my mind’s eye I see them now in the back of a dark, smoky primordial cave with my ancestors laboring over a bubbling cauldron as a voice asks, “Hey, Cox. Whatcha making back there?” But the record keeping was sketchy back in those days, so I had to let the patent fight go by the boards.

The colon cancer is just as pronounced with a solid majority of all male relatives dying from it. My own father watched his father and his uncles die from it, and then one-by-one his brothers. So I asked my dad as he was getting along in years if he had been checked. He looked me straight into the eyes the way a father does for emphasis and he answered, “What good would that do? They all went to the doctor for it and they all died of it just the same. They had surgeries and chemotherapy and they all had colostomy bags attached to their sides. And for what?” Then he looked at me with dead seriousness and said these two words, “Not me.”

Near his seventy-ninth birthday I got the call that my dad was in the hospital and not expected to live. His intestines had ruptured and he was eaten up with cancer, but he had lived at home and on his own terms until the day he died. He saw no use in prolonging his life by a year or even two by sacrificing his dignity. They rushed him into emergency surgery, and the doctor opened him up, cleaned him up, patched his ruptured intestine, then taped up the wound and waited on the inevitable. My stepmother tried to explain, “The doctor was so nice, your dad would have liked him. They took him into surgery and he was out in ninety minutes.”

The surgeon’s bill for the operation was over $35,000, and along with the hospital’s bill the total was over a hundred thousand. All to keep a dying man alive for twelve more hours, and my dad passed away almost ten years ago. His brother had the surgeries and the chemotherapy and was then too ill to stay at home. When they told him they were going to put him into a nursing home he protested, saying. “I won’t survive there twenty-four hours! I won’t live there!” He didn’t. He had hidden medication in his luggage and took it all, and then downed it with a warm beer.

Our for-profit health care system profits by prolonging life by any means necessary. Had my father not made out a living will they would have kept him alive on a machine until the money ran out. Because it was profitable; not because it was the right thing to do. Death with dignity and on our own terms is the final punctuation for a life of dignity. Prolonging misery is a tax on the living and a tax on the dying; one paid with coin, the other paid with suffering.