Collapse of the German Healthcare System and Lack of Clinical Acumen, Expertise, and Compassion Towards the Elderly

Our story highlights a profound failure of communication and teamwork within the healthcare system, underscoring the absence of a patient-centered approach. My mom (until February a still lively 86-year-old) has in the past 3 months repeatedly been admitted for the same condition - failure to be able to eat and drink due to ongoing nausea. And from February 2024 to the present, she has been deprived of the dignified care and personal attention every patient deserves, regardless of age.

For the system, she represents a costly, dying patient. The picture spearheading this article has been taken in February 2024 prior to her first hospital visit. Her condition has been consistently mismanaged due to a lack of coordinated care and failure to address the root cause of her symptoms—persistent nausea leading to an inability to eat. Each admission has been marked by misdiagnoses and inadequate treatment plans, reflecting a disjointed approach in her 6 admissions to date:

1. Constipation: Initially diagnosed and sent home after an emergency department visit. She had no constipation in the past 12 months.
2. Urinary Tract Infection: Diagnosed despite a perfectly normal urine analysis. She was discharged on antibiotics.
3. Influenza: Sent home with Tamiflu despite having absolutely no upper airway symptoms or fever.
4. B Lymphoma Symptoms: Suspected without any clinical confirmation whatsover of a lymphoma diagnosis by. Dr. A Chefarzt Josephskrankenhaus, in the setting of normal LDH values, and sepsis parameters consistent with procalcitonin 20, crp 120 and leukocytosis 17. He strictly forbade according to Dr. J his resident any further blood draws of the "dying patient".
5. Sepsis of Unclear Etiology: Antibiotics were started presumptively 48 hours before obtaining and sending blood cultures. Source to date never elucidated.
6. Severe Electrolyte Disturbance: Admitted to ICU and Cardiology /monitored beds 3 times within the last 4 weeks due to persistent poor oral intake since February leading to critically low electrolyte and vitamin levels. Culminating in the treatment of tachycardias in 180's ( known history of panic attacks with tachycardias responsive to benzos), and a systolic blood pressure of 60 with betablockers in the most recent episode this morning. Not done as part of the work up prior to betablocker were magnesium levels, ddimer levels rule out PE /DVT , cardiac troponins, lactic acid and blood gas levels.

Throughout these admissions, the MD's have consistently failed to adopt a multidisciplinary, patient-centered approach. Inexperienced first MD responders, without adequate supervision, and narrow view points dictated by their respective specialties were consistently incapable of entertaining broad differential diagnostics. The absence of coordinated care has resulted in repeated hospital visits without resolving her underlying issues. Instead of treating her as a patient deserving of comprehensive complex care, she has been reduced to a series of mismanaged misdiagnoses. The confirmation of the "perhaps" malignancy and end of life discussions at the bedside with the treating MD and the patient has not happened to date, instead has been deflected to her children (my brother and I) with shoulder shrugging indifference by the "supervising MD's" leaving us with nothing but presumptive diagnosis to go on. Rather than confirming a diagnosis each separate team of MD's has spent few minutes at the bedside, afraid at best or incapable at worst, to have to be the ones stuck with the task of talking about death and dying with the patient and the family, and hoping that in delaying a confirmation of the diagnosis the patient may pass in the hallways of care (at home, in an ambulance ) just simply not on their watch.

Her current path towards becoming a palliative care patient is based on a presumptive diagnosis of malignancy, which i have made privately ordering the necessary bloodwork, as I sought answers and expedited care out of desperation. Her case starkly illustrates the abysmal state of the German health care and sadly also the lacking clinical acumen of the physicians, and a total absence of empathy in the care of the elderly, the incapacity to listen to family members and the disregard of the opinion of a colleague who happens to be a daughter as well.

This is the letter i sent her doctors this morning. Mom wanted to be left to die, tired, humiliated and robbed of all her strength, after her third transfer to a critical care monitored unit within less than 4 weeks.

This is the final letter in a series of emails I have written to her care team in the last month, trying to draw attention to the main issue: failure to thrive absent any pain, or other symptoms such as vomiting or diarrhea, or fever, simply due to nausea which is not properly managed.

"Dear Dr. K,

I have tried to contact you via phone repeatedly yesterday and this morning. No one is responding at the number listed under the Uniklinik website as yours.

I am writing to you regarding my mother's recent rapid health deterioration and the significant challenges we have faced. Despite my efforts to expedite her work-up even using privately paid for testing and imaging, the process has been delayed considerably. Based on my 28 years of experience in the US clinical system, her work up could have been completed within the first 72 hours of her initial hospitalization in February 2024.

In 2024, today, in Germany my 86 year old mother is dying from malnutrition, severe untreated depression, and anxiety, under the assumption that she has a terminal malignancy, which has not been confirmed by any pathology. I want to stress that the only data to date is based in diagnostic lab and imaging ordered and paid for privately by me ( FDG PET CT and tumor marker laboratory tests), without the support of any of her treating physicians. This situation has unfortunately highlighted what I perceive as a complete failure of the German healthcare system. I attempted to reach you via the telephone number provided by my brother this morning, but I was unable to connect with you.

Given the urgency of my mother's condition, I would greatly appreciate your prompt assistance in addressing this matter. Your expertise and intervention are crucial at this point.

It is my clinical opinion that my mother is not eating or drinking according to her metabolic needs due to severe nausea. As such, I had asked that any surgical procedures be planned during her hospitalization after optimizing her clinical status. This should involve, at a minimum, calorie counts, strict daily monitoring of water intake and output, and daily electrolytes. In my opinion, her care plan should also include parenteral nutrition, along with daily potassium, magnesium, and multivitamin supplementation.

I have observed asymmetric pedal edema, and given her recurrent SVT episodes, this warrants a thorough evaluation for DVT/PE, including D-dimer levels. Additionally, considering her electrolyte imbalance, tachycardias, and potential malignancy, lactic acid levels and ABG assessments should be conducted. This is what I would expect my residents at Yale University in the US to present to me as their supervising attending during rounds in a situation like hers.

Our entire family supports my mother in all her decisions. A biopsy confirmation of the malignant nature of the uterine mass (3 x 3 cm) is essential, especially since it is may not be the only cause of her extensive paraaortic, retrothoracic, and cervical lymphadenopathy. Addressing her poor food intake with maximized Zofran and Mirtazapine dosing, and using medical cannabis for appetite stimulation and anxiety management, could prove very helpful in the management of her current symptoms. Over the past six weeks, she has endured severe anxiety attacks, and a holistic approach to her care is the minimum requirement for her well-being during this difficult time. She has been the ping-pong ball of German hospital care for the past three months and now only wishes to die to avoid further botched attempts at blood draws without appropriate ultrasound guidance.

As her daughter, it is my heartfelt wish (and hers) that she lives long enough to say goodbye to my son, who has taken leave from work in the US and will be here on July 1st. Without adequate medical support, I fear this may not be possible.

Additionally, I must mention that the current diagnosis, including tumor markers and FDG PET CT, was done privately and at my request. Despite this intervention, I am still observing her being shifted from Infectious Disease to Oncology to ICU and back, in one building today, switched to another tomorrow, just as MD's too many to count or remember are changing hands in her care. The lack of a multidisciplinary team approach in acute care, as I am accustomed to from the US, has resulted in a prolonged and fragmented process. Her full work up could have been resolved within two weeks with a patient-centered approach, instead, she is caught in a carousel of admissions and conflicting opinions. As both a daughter and a physician, I find this situation deeply disappointing and below any reasonable expectation.

Thank you for taking the time to read this email and for your attention to these urgent matters.

Sincerely,

Arina Cadariu MD MPH"

I realize that this scenario represents the fate of geriatric patients in Germany. As someone working in prevention and aging in place I wonder if this is the end we are expecting after putting in efforts for a better longer life. Patients from Switzerland, Italy and France have told me similar stories, themselves caretakers of dying parents, or elderly patients unable to get complex care. What i find disturbing is the excuse of every MD involved "this is what it is, it's the insurance system which is tying our hands" The paralyzing complacency after a lifetime of paying into a system to expect a dignified death. This is not an outcry against the insurance or health care system, but against physicians who have become complacent, who do not strive for excellency and who have lost touch with their humanity. The system can only be as good as those delivering the care.

Today, upon my brother's questioning, I reflected on this article and realized it was written in pain and impulsively, without reflecting on my why. As a physician, in turn I reacted to the reactive medicine practiced by all these MD's with a sense of frustration and urgency. Each decision to send my mother home with another misdiagnosis spiraled her health further downward. As a daughter, I am deeply disturbed by the inability of medical staff to show compassion or actively listen to my concerns. The defensive attitudes and lack of empathy made it clear that systemic changes are desperately needed here.

Scott Galloway 's insights resonate here: "AI is powering our search engines, medical research, and fraud detection... Judge a technical revolution by its utility, versus hype" (Apple). The utility of AI in medicine is undeniable. It can and will soon provide the accuracy and proactive care that the current system lacks.

Let's just walk through every turn of my mom's case and see where AI integrated at every turn could have improved everything and lead to an accurate and timely diagnosis. Today AI powered tools, like Watson, can analyze the patient's symptoms (those which had not been heard), history and vital signs in real time. And it can predict the complications I have witnessed alerting the medical team to monitor specific biomarkers closely - ddimer, lactic acid, the blood gas, and her electrolytes, crp, procalcitonin. It can recommend further tests, such as in her case - DVT, PE imaging for instance. AI can analyze labs instantly - the very same labs patients in the US view instantly thanks to the CURES act - flagging abnormal values and correlating them with the patient's symptoms. And most importantly AI can provide a differential list ranked by probability increasing MD diagnostic accuracy. Deep Mind's AI today is capable of monitoring the patient's signs continuously, predicting deterioration and suggesting interventions before the situation becomes critical - such as for example correction of magnesium levels of 0.2 and critical potassium levels prior to development of irregular noncardiac arrhythmias precluding surgery for instance in her case. Most importantly AI can coordinate care across the departments ensuring all MD's work as a unified team. How much shorter her stays could have been if AI predicts the need for specialist consultation and schedules them proactively, reducing wait times, and improving continuity, rather than shuffelling her around every 2 days, changing rooms, down corridors into different buildings, new doctors irritated by her transfer and stubborn persistence to live. Imagine my mom could have received consistent care (like she would have in the US)from ONE dedicated team, reducing the constant risk of miscommunication, and ensuring that all treatment plans are based on a cohesive treatment plan. And most amazingly my mom could have gotten rapid diagnostic confirmation through tools like liquid biopsies, non-invasive tools for accurate detection of malignancies. Watson for Genomics identifies any genetic mutation associated with cancer, providing actionable insights for targeted therapy. This would (still may) have most certainly reduced the time (now > 10 weeks) to diagnosis and maybe even have offered her a chance of treatment.

Looking to the future, I know that while the win may not be there for my mother, AI will ensure that when it’s my son at my bedside, he will benefit from a system that recognizes and acts on critical signs promptly. This transformative potential of AI will redefine healthcare, blending technological precision with human compassion to create a truly advanced and humane medical practice.

Our family experience in these last 3 months represents but one example showing that in medicine embracing AI is not just an upgrade but a necessary evolution. Those who resist will be left behind (good riddance), while those who adopt AI will lead the way in delivering dignified and effective care that every patient deserves. The complacency and defensive attitudes in the current system are no match for the proactive, precise, and compassionate care AI can deliver. This is the future of my medicine.

"Spread your attitude, don't absorb others" Thank you Dan Goldin for showing me the silver lining.