I would like to discuss the expenses that are incurred at the end-of-life. The unending spiral of nursing home, to ER, to hospital bed and back to nursing home bed needs to be re-examined. If there were any good endings or good medicine being practiced, then this would be another conversation, but there isn’t. An enormous amount of healthcare dollars are being spent to prolong the existence, not meaningful life, of a large number of patients. This must stop. If the healthcare dollars were unlimited, then this conversation would be moot, but they are definitely limited. We, as a society, must make the hard choice of where to spend the funds. My personal preference would be on the pediatric population, with the concept in mind that saving a child potentially provides for a long and productive life. Let me provide an example. The usual ER patient that I am talking about arrives by ambulance with a fever. The patient is severely demented, cannot walk, cannot talk, cannot perform basic bodily functions, and relies on a feeding tube for sustenance, a catheter in the bladder for elimination and usually has multiple large bedsores due to their immobility. In many cases, no one has visited the patient in months and they would not be aware if they did. After a very expensive medical work-up in the ER, they are admitted by the primary care physician for treatment of the probable cause. If everything goes well, after thousands of dollars and a few days in the hospital, they return to the nursing home for another month or two of existence. This scenario is played out in every ER across the country, every day. This may seem like a jaded view of healthcare, and maybe it is, but it would seem that at some point we would want to interrupt the cycle and just make the patient as comfortable as possible for their remaining time on this earth. What is the point in subjecting these patients to an endless cycle of painful procedures, just to return them to their nursing home existence. It seems incredibly selfish, wasteful and pointless.