Commentary : A Life Is Lost in Tangle of Red Tape : Medicare: Unbending rule forces patient into unwise stay in hospital, where she gets worse instead of better.

I lost an old friend recently. She died and none of us were ready. As her doctor, I had done the best I could, but it wasn’t enough. My hands were tied because of bureaucratic regulations.

Her daughter had stayed at her hospital bedside speaking soothing words to unhearing ears, hoping to break into the delirious ramblings and bring her back to say goodby.

Her mother, my patient, was expending a tremendous amount of energy visiting places that we could not see. There was relentless thrashing about, but my patient’s nonsensical phrases reflected her quiet inner spirit in that her words were soft and gentle repetitive ramblings of God and the beauty of things she had known.

When I tried to make the daughter go home to rest, she refused, noting that her mother wasn’t afraid of death, just of the process of dying. The daughter felt she had to be there to help her mother through the transition.

When my patient died, it was in the early morning hours. She was alone in her hospital bed, but she was enveloped in the love of her family and the respect of the hospital staff that saw through the rantings of fever to the beautiful woman that she had once been.

Why did she die? I believe she died because of a Medicare regulation.

I spent hours on the telephone trying to find a way around the regulation, which prevented me from doing what I felt was medically indicated for a short-term, simple problem: a collapsed vertebra.

But there were no shades of gray in this regulation. It was black or white without any exceptions. There was no humanity because bureaucracy has no time for humanity.

Christmas was a creative time for my 74-year-old patient, whose name by the way meant “beautiful.” And indeed she was just that. She had been at home at her desk writing her annual Christmas poem and had turned abruptly. She felt a dull ache in her back, but, in keeping with the spirit of Christmas, she had tried to carry on.

The pain intensified and became severe when she coughed, which she did frequently because of a chronic lung problem.

We started treatment with pain pills, but that wasn’t enough. We taught caring neighbors and the husband to inject her with pain medication but she got so groggy that she couldn’t raise her hand to eat or lift herself from bed to go to the bathroom.

Her husband was too frail to assist. We sent nurses to her home, but Medicare regulations permitted visits only two to three times per week. The family could not afford private-duty care because of the expense of a previous 10-day hospitalization that could have been avoided with home care--except for Medicare regulations.

We eventually decided that a short-term nursing home stay, probably for one to two weeks, would take care of her needs.

The medical social worker concurred, but noted that she would have to go to an acute-care hospital for three days to qualify for Medicare reimbursement. I explained that I would not consider that option.

With my patient’s chronic lung condition, in her debilitated state, we would be exposing her to a lung infection because of the significantly resistant strains of bacteria that are lurking about in hospitals.

These mutated strains occur because of the types of antibiotics that are used. Nursing home placement would not expose her to this danger to the same degree.

But there were absolutely no exceptions to this Medicare regulation.

My patient never made it to the nursing home. Twenty-four hours after admission to the hospital, she developed pneumonia. You know the rest.

To be coldly analytical, it would have cost $89 per day to care for her at a nursing home. Without any complications, it cost $400 per day to care for her at the hospital. That cost escalated into thousands when she became ill.

Worst of all, because of innumerable bureaucratic regulations, doctors are being told how to practice medicine, often to the detriment of their patient’s health.

And there is an emotional toll. In spite of what the public has been told, or might think, we doctors do care.

The emotional strain is devastating. How do we protect ourselves so that we don’t grieve when we recognize a needless death, which is against all that we stand for?

I suppose we could build a wall around our emotions and render our medical care as coldly as the bureaucracy administers its laws.