Health Care Thoughts: Please do everything you can….
Health Care Thoughts: Please do everything you can….
…. to keep mom/dad alive.
Physicians and nurses often dread these conversations. Any of us who have been on the family side of this know how agonizing it can be.
And I know even mentioning this can cause a firestorm.
However, there are some unsettling issues raised by these conversations, issues that are a sort of third rail of health care (and no there are no proposed death panels).
First, does this attitude increase suffering? Many of the elderly have 4 – 10 major diagnosis (COPD, CHF, PAD, diabetes, a-fib, etc. etc.) and very little quality of life. Especially problematic is the ping-pong that often occurs between the hospital and the nursing home (families often see a transfer to the hospital as a magic bullet, physicians often give in).
Second, Medicare is paying for a great deal of hospital care that may have very little value.
No one wants the government making these decisions, but at some point the care is futile and often painful. Some patients and families deal with these issues well, others do not.
For my part, I have a health care POA, a living will, and everybody in the family knows the course of action I want in various situations. Ditto for Mrs. R. It is still tough though.
Tom aka Rusty Rustbelt
In the final years of his life my fathers greatest fear was being kept alive in a vegetative state by some machines.
After he died we found six (6) different living wills in his papers.
“Medicare is paying for a great deal of hospital care that may have very little value.”
Mebbe so. What I observe, as a ordinary citizen, is quite different. And the “last six months of life” statistics are skewed by selection bias. (Of course they all died.) Also, I have seen stats that say that the wealthy spend a great deal on hospital care aimed at prolonging life in senescence. Not that I trust that, but if those figures are lumped in with Medicare costs, the result could be unrepresentative. Is Medicare being taken for a ride by oldsters who are clinging to life, their families, and hospitals? I have seen scare talk, but nothing convincing.
No one is taking anyone “for a ride,” it is just the result of good intentioned decisions that are easy when someone else is paying.
Since Dan put this up let me make an announcement.
Last night I signed a contract that will keep me busy as an author and editor for at least 18 months and perhaps longer. In this new era of health care I will be writing and rewriting “how to manage” materials for physician groups and other providers.
Added to all of my other committments I will likely not be around the blogosphere as much, although I will lurk when I have writers block or just get bored with my own writing.
In another possible milestone Mrs. R is starting to think about hanging up her stethoscope, a tragedy for her elderly patients. The physician and emotional wear-and-tear is getting to her, and she is working scared; scared mostly of regulators and somewhat of families and lawyers.
Well my two parents are 67 and both very sick. Their assited living care and med bills are through the roof. They absoluteley need 24 hour supervision, as they both have different forms of dementia. My mom is physically great and will probably live a long time, at great expense to medicare, and at some point medicaid. My dad does not look so good.
Nobody, no matter how rich, gets out of this alive. Money may help put off the inevitable for a bit–Steve Jobs–but at some point, everyone including the wealthy wants to die as peacefully as possible. If our medical profession spent even 1% of the time , money and effort in helping people die comfortably as it does in keeping them alive miserably, the problem would solve itself.
Paperwork is done. Hopefully it is airtight.
I was talking to a doctor last week and told him that sometimes doctors just expect that people will follow their medical recommendations even when those recommendations might keep them alive to face increasing disability and/or misery. To his credit he acknowledged that doctors look at problems like a car mechanic fixing the current problem and do not step back and take the condition of the entire car into account when they advise their patients. So if a person with multiple problems (diabetes, heart attacks, etc.) will be saved from the kindness of a massive heart attack, they will push for a heart operation. Then that person can slowly die of increasing degrees of disability and/or pain from their other problems. Perhaps if the doctor evaluated the entire picture and discussed it with the patient, the patient would better understand their options before deciding to accept a procedure as the best route.
DEATH PANELS, DEATH PANELS, DEATH PANELS!!!!
Liberals are coming to KILL MY GRANDMA –AAAAUUUGGGHHH!!!!!
Get your g*ddamn govenment hands off my Medicare!!!
Oh, sorry… was channeling the Tea Partiers there for a second, not sure what came over me. Now back to your reasoned adult conversation.
Eh, they give it a shot.
Of course when it was propsed that medicare pay for counceling about these issues… DEATH PANESL!!
Just trying to be vivid. 😉
But I do have a question as to the magnitude of the problem.
Glad you came back from the edge…..
Sorry, that is tough on everyone, including the children. Especially the children.
Pat Robertson, largely irrelevant to everyone these days, found a way to get himself back in the news.
Pat Robertson: Divorcing spouse with Alzheimer’s is justified
New website, Vince Mor is a major figure in long-term care research. FWIW.
http://www.youtube.com/user/ProviderMagazine#p/u/3/rO2rE5rTZ20
Wars are easy, when SS and medicare are paying for them.
The F-35 is on life support, as is the F-22, and about $1.6T in the rest of the 100 most costly, late, untested, no mission, scrap and rework DoD weapons.
The only life support pundits worry on is that which helps people and is paid by medicare with money that should go to wall st.
Life support for war profiteers and banks have a blank check.
God Bless the coalition of Family Values! Guess marriage vows like “In sickness or in health” don’t mean as much as they used to, even in Jesusland.
STR,
Incentives matter. Pat Robertson is 81. This here bio of his wife (http://www.cbn.com/700club/guests/interviews/Dede_Robertson_100104.aspx) indicates she met him while he was in law school. Wikipedia says Robertson got a Bachelor’s degree in law (that was as far as he got in law) in 1955. If she was as young as 20 at the time, she’d be 75 or 76 now.
Another source: she is only two and a half years younger than he is: http://marriage.about.com/od/religious/p/patrobertson.htm
Put another way… it is possible she has Alzheimer’s.
The second link indicates she might have had some sort mental disability when they met:
“Dede Elmer was a Yale nursing student who met her future husband at a sorority party to which the law school men had been invited. While trying to light some candles for the party, Dede caught her hair on fire, and Robertson came over to help her out”
More than that:
“Before I even realized my hair was on fire, a tall man with bushy eyebrows was putting it out,” she recalls more than 35 years later.”
All I know is, neither I nor anyone I know has ever set their hair on fire. Furthermore, I’m pretty certain that if a normal person ever set their hair on fire, they would have the self-awareness to realize it.
If I had to bet on it, I’d say Robertson’s opinions are self-serving.
A country which spends as much for war and life support for weapons and space missile manufacturers (congress, who would guess Fl and Tx, just impressed on Obama to schedule $18B for a cluged rocket to lift using Appollo and Space shuttle pieces to put heavy stuff to low earth orbit in 2017) as the rest of the world combined should afford its poorest hope.
I have seen a lot of end of life in the past 10 years.
Several took the hospice approach and went easy and comfortably.
My parents took the “try everything” strategy. Months on ventillators, etc in ICU. I was in all the decisions and there was “always a hope”.
For me, I choose hospice.
I will keep pointing out that social darwinism (government should not interfere) is only for poor people the top oners get bailed out.
Anna
you completely misunderstood my position on taxing the rich, so i hesitate to offer an opinion on this..
i think there is a not wonderful way this can be “solved,” but it can’t be done by a bureaucracy, guilt-fearing children, or even “in advance” by the future patient. you don’t know how you are going to react to the event.
maybe we all need to go back to church and get counseled our whole lives on the inevitability of death and the honor of facing it bravely. no special church is meant. i think the romans and the vikings and the eskimos had something like this in their cultures.
i am quite sure if i was a doctor i would not push for heroic end of life care. but i can’t say i would say the same if i had a parent who wanted it.
Mom failed hospice the first time, but made it on the retake.
She made clear to us early on what she wanted, and we listened to her.
well, i was thinking that when they say
doctor, please do everything you can
they mean, please make her comfortable and don’t prolong her suffering.
and while i’ll regret saying this, the doctor knows more about what’s coming,and what’s possible than the relatives, and maybe part of his “calling” is to make the right call.
I have been accused on occasion of having my hair on fire………………..
The physician may not know as much about overall circumstances, and has no specific right to “make the right call” if it contradicts the wishes of patient and/or family.
And no, “do everything you can” usually does not mean comfort care.
The movement to bundled payment systems for Medicare will put serious pressure on the hospital and the physician to put some sort of reasonable limits on end of life care. How that all works out will be interesting over the next decade or so.
At least half of the doctors I have encountered are idiots and almost ceratainly regularly kill patients. Fortunately, they have Police SWAT teams on call to eliminate competition for thier services.
Praise the Free Market!
“The physician may not know as much about overall circumstances, and has no specific right to “make the right call” if it contradicts the wishes of patient and/or family.”
The ethical dilemma for the physician is obvious and more so if the patient has “family” making their decisions. Quality of life is a subjective concept and prognosis of recovery and subsequent quality of life is to a large degree guess work. Add to that the family decision maker and the unknown factor of intent and the physician can find him or her self in an ethical corner. Sure we all have a good idea of what we wnat for ourselves in such circumstances though that is often before we come to that cross road. Facing a decision of life or death can change one’s perspective. So the physician can be between the proverbial rock and a hard place.
The answer to the problem may be easier than we think, if not ideal. From Kimel’s post above, we can see the effect of private health insurance industry oversight. Claims which become too costly and little hope of prolonged beneficial effect are likely to begin to be rejected by private insurance over seers. From Mike’s example, allow Company B to sign up your elderly loved one’s and let the private insurance carrier be responsible for life suppport decision making. I can just imagine what prior approval rates might become. It won’t be pretty, but it will reduce costs and put the decision making where it belongs, with the third party paying the bills. Hopefully someone like Mitch McConnel will be the first such patient.
rusty
no doubt you are right. i was just presenting what would be my point of view. i have seen enough doctor arrogance to be very leery of recommending institutionalizing it.
i have no way of know what is in “people’s” minds. but in general i think they don’t know what is in their own. they want to be relieved of the potential guilt of acceding to mom’s death, but they really don’t want to think about her misery in being forced to live. and we may be coming to a point where the expense of forcing everyone to live to the last drop is really more than we can pay, not just more than we want to pay.
rusty
and yet here you are suggesting exactly what you said doctors had no right to do.
PT
as i replied to rusty, you are undoubtedly right. i will fall back upon my suggestion that we cultivate a culture of courage in the face of death.
then i think i might be willing to let those who can save up all their money so they can give it to their doctors to fight a heroic battle to prolong their lives.
wow, jack
in some ways you think the way i do (facing a decision… can change our perspective) but you end up in a place i am not sure i understand.
“That spot on your skin is cancer. It is going to kill you. Here, take these two pills and save yourself a lot of trouble and the insurance company a lot of money.”
I didn’t suggest anything, it is the Obama administration specifically DHHS_CMS writing the policies. And to be fair, this was under development during the Bush administration.
I suggest we need to have more discussions – I don;t want to make decisions for families.
coberly
I’m surprised by your reaction to my comment. Re-read paragraph two of that comment and try hard to see the tongue pressed agianst my cheek. I did say that I was hopeful that Mitch McConnell woould be the first victim, I mean patient.
Rusty
fair enough. i have had to make decisions like that. i didn’t like it either.
and while i agree with you about not wanting the doctor,or worse , the insurer make those decisions, i am sure the doctor is in a better position to know what “do everything” means to the patient. maybe he could find a way to help the family make the decision. why he gets paid the big bucks.
jack
I was with you in paragraph two. too dense to see the irony in paragraph three.
you have to admit it’s rather close to what rusty says is happening. i picture a world where the doctors get out of “making the decision” by saluting smartly and saying “yes,sir” when the insurance rep tells him to pull the plug.
i don’t like the idea of “letting” the doctor make the decision either. but you have to admit there is a problem both from the point of view of a patient condemned to months (or more?) of vegetative, or perhaps painful, existence when life is over in all but EKG, because the relatives can’t bring themselves to accept the “guilt” of making the decision. and while i hate to be crass, if “the rest of us” end up paying for a lot of those expensive terminal illnesses you are going to see “us” make the decision in a way that will NOT be good for us.
me, i hope to be a long way from a hospital when i can no longer care for myself.