Almost three months after his death, Stanley Wilks is still a subject of medical discussion. Now that the fight for life of the 44-year-old Army mathematician has been waged and lost, the questioning is of an ethical, rather than clinical, nature.
More than 270 days of energy and emotions of surgeons, internists, residents, nurses and $248,486 were expended in what eventually proved to be a futile effort to overcome the series of infections that plagued Wilks from his admission to the George Washington University Medical Center late last November until his death there Aug. 7.
In an era of growing concern about rapidly escalating health care costs, the illness and treatment of Standley Wilks appear to provide a perfect case study for examining such troubling question as: How much health care is one individual entitled to? What is "ordinary" and what is "extraordinary" when it comes to maintaining life? Is enough ever too much?
When the case is examined more closely, the questions and answers begin to blur; according to those most familiar with the care of Stanley Wilks, there never was a time when his case appeared hopeless.
Additionally, "Stanley may be a good example of the symbolic life. It makes us feel we believe in life, in its value. We may be able to tolerate a certain number of Stanley Wilks,"said Dr. Joanne Lynn.
Lynn is an internist and a Robert Wood Johnson Clinical Scholar, one of the handful of young physicians around the country chosen by the Robert Wood Johnson Foundation to study and examine the larger, societal issues of health care at the same time they are in clinical pratice.
"The question is not only 'was this the right thing to do,'" said Lynn, "and it was there tremendously expensive. But was there anything else to do?' Each decision looked logical," she said.
Wilks, married and the father of four , entered the hospital suffering from pancreatitis, an inflamation of the pancreas. He got progressively more until "he was as sick as he could be and still be alive," said Dr. Glen Geelhoed, the surgeon who treated Wilks.
At one point the decision was made to paralyze Wilks with curare, a substance used by some Amazon Indian tribes on their poison darts, in order to put him on a respirator in the hopes his system would then gain enough strength to overcome various infections itself. He remained paralyzed for 72 days, living in a kind of suspended animation.
Wilk's plight drew worldwide attention following the publication last April of an article in The Washington Post focusing on the unusual nature of his treatment and the length of time he was kept on curare.
"The stories (at the time) tended to emphasize that he set the Guinness Book of World Records record for having been curaretized on the machine," said Lynn. "The way it (the case) comes across (from reading the cartons to records) is much more fascinating and characteristic of all medical care) and much more real.
"The decisions were made day to day, or week to week. He was put on curare" because he needed to be immobilizes on the respirator. "There were decision points every couple of days," said Lynn "and each one was dealt with individually."
Wilks' first surgery was Dec. 2, 1976. A few days later "he was up and walking around with all his tubes. At Christmas time he got much worse, but then he got better. By the end of January (after he had been on curare for a few weeks) they were talking about him being a little awake, but by the end of February he had to be reparalyzed.
"By the end of March there's a note (in the records) saying "this patient is awake and alert and feeling much better," continued Lynn. "The week after that he was transfered back to the floor. He'd got better, worse, better, worse. It wasn't until the end of July that things really got bad. By the 28th there's a note that he looks like a new man. By the 29th his fever was up and he had an infection in his blood and then it was "all" downhill. The infection was not directly related to the original disease.
As an example of the roller coaster course of the disease, by mid-April Wilks was receiving visitors in his hospital room and Geelhoed was talking about sending Wilks home within about 30 days. The surgeon even treated about a dozen nurses and interns who had worked on the case to a celebration held in the belief that Stanley Wilks had finally made it.
"We don't have opportunities in midicine to sit down and make grandiose decisions," said Lynn, who because studying the case closely because of her interest in bioethical questions. "It's bit-by-bit decisions and there's no chance for economic analysis. There's no point where it looks like they could have made any other choices. Like on July 4 they noted that (Wilks) went out on the porch with his family and enjoyed the fireworks. How could they stop?"
Right to the end, Stanley Wilks was "saying things about how he wanted to get better and get well.He was concerned about his family and he wanted to go the distance," said Geelhoed.
"Was it worth it? We can ask that crassly in a lot of ways," said the surgeon, during a lengthly, philosophical discussion of the case. "For example, did we get $300,00 woth of information, or medical education, or health staff experience or nursing training or something like that? No.
"It wasn't really anything we did that was experimental," Geelhoed continued. "Everything we did had been done before, probably for a shorter period to time. We just put a couple of extra decimal points behind it. So, in terms of what my interns would call a 'science fair project,' no, we didn't gain anything to the extent that, he did not survive.
"But as a human spirit who was struggling against the odds, and we were able to help in his on-going determination to make it, it was very much worth it. It was his own plea for self determination that was, in great measure, something that kept everyone going for him.
"If the man had pleaded, 'aw, come on fellas, let me off the hook, this is painful and I don't want it,' there is no question as to what we would have done - nothing. Less than nothing." said Geelhoed. "We would have taken some measure to assuage his pain, which would have (as an unavoidable side effect) shortened his life And that means we were listening very carefully to what he was saying."
Many strong narcotics, such as morphine, depress the respiratory function and often speed up the dying process of terminally ill patients.
"There is a great deal of one's own investment in fighting with mortality," mused Geelhoed. "You're staring your own mortality full in the face, and you've got to isolate that from the patient. It's like, 'if I can lick it for him, I've got it beat for me.' You're not facing Stanley Wilks' death, but your own, and you've got to isolate your own feelings" from your feeling of what is really best for the patient.
"I don't consider Stanley Wilks a medical miracle, I consider him sombody who had a large investment in human resources, and the human resources. I think, are manpower and consumable supplies that come from human resources, like blood, plasma, things of that type. I don't think there's a giant machine out in the sky that prints hard currency, but the inflationary impact of Stanley Wilks as a single patient is minimal."
Wilks belonged to the George Washington University Health Plan, a health maintenance organization. as such, his bill of almost $250,000 is entirely paid by the health maintenance organization, but the plan administrator said Wilks expenses will add only negligably to an upcoming premium increase for members of the plan.
Geelhoed continued, "as a model for what is happening nationally, the inpact of Stanley Wilks is astronomical . . .I'd like not to have any patient become a model" for the kind of treatment any other patient is entitled to.
"We is entitled to extraordinary care? Geelhoed asked, repeating a question put to him and greeting that Wilks' care was extraordinary. "It is those people who look like they're going to be able to give a return on their investment in some human value." CAPTION: Picture, STANLEY WILKS . . . 270 days, $248,486 cost, By Margaret Thomas - The Washington Post