(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)
Bread and Circuses
This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.
The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.
The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.
Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.
It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?
No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.
In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.
The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.
Things Cost What They Cost
I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.
Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.
Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.
He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.
Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.
This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.
It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.
You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.
Throwing Good Money After Bad
I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..
For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.
My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.
Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.
My mother is in the final stages of dementia, probably Alzheimers, and we’ve opted to keep her at home with the help of the local hospice. Medicare is paying for weekly nursing visits, a wheelchair, and meds to manage her dementia. We’re paying for a home health aid to help with her care. The cost of this option is far less than than the $10,000 per month that a nursing home costs.
She worked as a nurse in nursing homes for 30 years and long before she became ill knew that she didn’t want to be warehoused. We could probably extend her life by a few months, maybe more, but she wouldn’t really be there to enjoy it. It’s hard to say what she is thinking but we can get her to laugh and smile a few times a day and try to make the days pleasant enough. There are bad days and parts of bad days, but by choosing to let her body tell her when it is done, she is avoiding months or years of really bad days for her family and for herself.
She made her choice based on seeing what happened to her patients. I think that as more baby boomers see their parents die slo lingering painful deaths, they will make choices for themselves and for their relatives that don’t prolong life when there is no hope for a good life.
I loved it. And oh so true. FREE=MORE
Keep up the great work
After signing all the necessary papers in a lawyers office, I still worry that my children will try to override my wishes and demand that ‘everything must be done’ endlessly as I drool in a nursinghome. I’ve watched them do this to their in-laws (I’m outliving those), though I know some of them tried to avoid it. Now, I’m wondering: if I get legal papers drawn up that they will have to sign if they want to stay in my will that whoever of them insists that ‘everything be done’ to keep me alive when I’m clearly dying, those will have to pay all the costs of my extended ‘life’. I’ll just have to check this out. You know, as you get older, the younger generation thinks you’re senile by way of being old. Arrogant. I take excellent care of my health and when that heart attack comes (if it’s to be that) I hope to be alone, not found til it’s all over. I love life, but I’m not afraid of death.
One other thing: I consider “health care” what I do every day to take care of my health. People go to doctors, etc, for MEDICAL care, not health care. Thank you for using the correct terminology in your post.
I recently got into this argument with some friends about this. They all wanted $7 birth control (it had just increased to $15/month) and the HPV vaccine to be covered. I pointed out that $15/month really wasn’t much for most college students at a private school (you can argue with me until you’re blue in the face about this, but really the extra $8 amounts to one fewer keg party/month or one more hour of work/month at your work-study job), and that they would just raise our insurance premiums next year. I’d like to point out that my friends would complain about that too.
After a while, one of them stomped off and refused to talk to me for a week. Insane. Everybody wants something for nothing.
I agree, completely. During our mandatory “ethics indoctrination” during the first few weeks of medical school we had a topic regarding a million dollar treatment to separate conjoined twins, with less than a 1% chance of survival by one of the infants (the other was allowed to die). Of course the infant succumbed, having never left the hospital, and having known most of the hospital staff more than she knew her parents. The parents were drug addicts, chain smoking, trailer park honkies who could clearly not afford the care of their daughter nor were prepared to take care of her or adjust their habits to support her pulmonary complications.
After several minutes we finally came to the question: was it worth it? I, and a handful of my classmates, realized the complete absurdity of the heroic treatment plan and the absolute waste of money that this encompassed. Unfortunately there were too many of my classmates who believed, and still continue to believe, that we should do whatever we can, regardless of the cost, to save a life. I hope that more people realize the futility in this kind of thinking and follow your common sense.
Excellent article (besides the tirade at the beginning in regards to the left).
that post was as long as it is true. some of your best, Panda. it seems sometimes in our efforts to empower people and make them feel validated, we bestow upon them decisions that they cannot make–either because they intellectually don’t understand the prognosis and its implications or because they’re blinded by their feelings and snared in the web of moral hazard (moral hazard ostensibly being one of your main themes, here).
I think one of the greatest mistakes we’ve made as physicians is allowing our patients to become partners in healthcare. There is a field of medicine called patient advocacy that sounds noble in that it allows patients to take part in their care. The problem with patient advocacy’s equal partnership is that the business is sure to fail if one half can’t carry its own weight. I recently had a patient who had been smoking up to 200 packs of cigarettes a year. He developed a nasty cancer of his neck that was eroding into his carotid artery and needed surgery, chemotherapy, and radiation therapy to keep at bay. His condition required multiple hospitalizations, leading to a monthly healthcare bill of $10,000-$20,000. Just like many of our other patients, his government-funded insurance plan would only pay the doctors and hospital staff the minimum amount necessary to keep them from kicking the patient out onto the streets, while at the same time pulling from Americans’ pockets their hard-earned cash, all in an effort to prolong the life of a man was too stupid to read the side of a box of cigarettes.
Patient advocacy has become a plague upon our national healthcare system. It’s what leads patients to believe that Wikipedia is more knowledgeable than a physician. It sets up unreasonable demands by patients for absolute perfection and divine intervention from the doctor’s hands. And when anything falls short of miracles, patients know that it’s okay to sue a doctor for more than the cost of the intervention itself.
My father, w/pacemaker/open heart surgery 2 yrs prior, exhibited signs of heart failure a couple of yrs after the latter and was taken to an ER. After a week he was trf for rehab to a nursing home/rehab (1/2 & 1/2), leaving the hospital w/staph infection. At rehab the Dr ordered NO Coumadin (blood too thin)but on the weekend a staff member instead gave him 2 double doses of Coumadin. On top of staph and bleeding out he developed infection of his bladder/kidneys; bacteria introduced via the cath, no doubt. Bedsores developed rapidly. I was able to track down & corner attending Dr after 2 wks to request transfer to hospice as my father realized he would not survive this onslaught and exhibited signs of impending death. Attending refused to even discuss the possibility of death or hospice. A signed DNR was on file, his organs were shutting down, CHF symptoms manifesting again, staph still present and unchanged, internal hemorraging continued, b/k infection still present, lost 20+ lbs since admitted, vomited blood, urine color dark w/blood, experienced extreme pain when staff forced food despite stated wish to not eat, and although staff was aware water intake low they repeatedly failed to provide water to him (we did so every time we came and every time we came a staff member would comment on his lack of water intake but did nothing toward providing water to him) and on week 5 he was re-admitted to hospital in the throes of acute renal failure. He was kept alive but still staff did not agree to my mother’s and my repeated requests to transfer him to a hospice. They proceeded with two procedures that were obviously futile and it only prolonged his suffering. Finally after the second procedure I again expressed our wishes regarding hospice & this time a nurse in recovery heard me and honored my request, setting the transfer in motion. (an angel) & as we waited for transport a chirpy young woman bounced into the room announcing that my father was scheduled w/speech therapist to determine “reason for difficulty swallowing” at which point I finally went off, advising that she get out and not come back and that his “difficulty swallowing” was due to the fact that he was dying and therefore being transferred to a hospice.
The moral of my father’s story being told at this time is to illustrate to those who are telling only one side of the story when they assert that the elderly with no quality of life and multiple fatal conditions are kept alive at their family’s insistence. Clearly my experience reflects the opposite: despite his written wishes the hospital would not let him die after that “healthcare” facility did everything in their power to see that he did die; and the hospital kept him alive and were planning to continue robbing him of dignity and the right to die in peace as he wished. The hospice was, in direct contrast to the hospital, concerned only for his comfort and treated him with kindness, demonstrating the respect he, and we, should have been shown by hospital and nursing home staff all along.
And, one more thing: it seems all we hear for the past few years from both the politicians who want to go on robbing the social security funds and medical personnel who view us as a financial drain rather than as human beings whose lives are of some value is how much it is going to cost for the baby boomers as we retire for social security and medical care.
Because we happened to be born into a large generation is not justification for such a blatant display of resentment for our very existence as we retire after working and contributing for 40 years during which we didn’t hear a peep from either group about being a drain on society. We paid into the fund and we should draw from the fund. The generation that soon will be entering the workforce, the Millenium generation, is an even larger one than ours so there should be no problem on the social security issue and I don’t think boomers will be warehoused and drooling for decades being kept alive but sucking the life out of hospitals/doctors.
Frankly, this display of vindictiveness in anticipation of something that might not,& probably won’t, materialize anyway are real revealing; and there are some some serious character issues exposed in that hysteria.
All this disregard and disdain toward us in place of the respect we do deserve is galling to say the least. If it weren’t for boomers your generation (X, is it?) wouldn’t even be here.
As for the politicians: they’ve stolen from and robbed the fund that belongs to all of us and should be there for all of us to offer up as their tithings while sacrificing us in the years that are supposed to be our reward for all the years of working and raising children and taking care of our own parents (and doing it without disrespecting them nor resenting them for still being alive) simultaneously to place us alongside our ss money as sacrifices on their altar of insatiable greed where they grovel and worship their god. (hint: their god is green. Give up? Starts with an “m”. Oh you’ve gotta know this! It’s m-o-n-e-y;what else?)
To them I say you broke it, you fix it. I’ve got an idea: how about instead of spending a billion dollars a month of our tax dollars to kill people in Iraq (5 yrs & counting)for no reason and put that money into the social security fund? That would solve two evils in one move, and maybe then we’d stop hearing how terrible baby boomers are for reaching our retirement years.
My grandmother, who lived until 90 and had one yearly check-up, and as she often said, outlived 4 doctors. Her Aunt Dolly lived to be 104 and I doubt she ever saw a doctor but if she did it was probably after age 100. I plan to do the same — so this is one boomer that nobody need worry about draining their resources. Something tells me that there are a lot more like me. We don’t trust medicines big pharma cranks out, advertises, and sells at prices netting obscene profits because it goes against our grain and we do read labels –and inserts, too. The side effects get more and more deadly and it sure smells like an experiment in which big pharma uses us as the guinea pigs without our knowledge or consent while gouging us to make an obscene profit.
We don’t think doctors are godlike creatures as our parents’ generation saw and treated them. We aren’t gullible and won’t blindly accept and do whatever a doctor tells us to do. We have the Internet and we use it.
And the times they are a changin.’
“Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon.”
Sorry Panda, but you don’t really know this and your assumptions are dangerous. You are saying you know what would have happened if… You can guess, but you sure sound convinced you know….I’ve seen lots of men and women survive MI’s. True, some die. But I sure wouldn’t assume you have saved this mans life.
This kind of thinking(Not discussed in “How Doctors Think”) leads to the “hero” mentality that drives docs to operate or intervene(DO SOMETHING!!)when decisions need to be measured carefully.
I’m not saying you didn’t act appropriately with this patient, but this sort of thinking drove vagotomies for gastric ulcers, back surgeries for bulging discs…
Sorry for the criticism.
I didn’t read the whole article. But I agree, we need to advocate for appropriate decisions. And knowing the natural history of an illness is critical for making these recommendations.
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(I did not save the patient’s life, the interventional cardiologist did. And no, he probably would not have survived this heart attack. Even if he had the resulting morbidity (CHF, arrythmias, free-wall rupture, etc.) would have probably finished him off soon…which is my point. Today he is good for another twenty years. Fifty years ago he would have lingered for, what? a year? Two? -PB)
“as ineffectual as rearranging the china while the bull still rampages”
Take a look on YouTube for the Mythbusters episode where they put a bull in a china shop. The bull didn’t touch a thing. It neatly avoided all the tall shelves covered with delicate china, even though it was moving at a pretty good clip.
I get the gist of what you’re saying, of course, but that phrase is now anachronistic because it’s not at all true.
“I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,†if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.”
Take a look at John Stossel’s recent peace on health care. It’s more or less a rebuttal of Michael Moore’s SiCKO. He points out that if we were to have grocery insurance, we wouldn’t buy a pound of ground beef, we would get four pounds of filet mignon. Who cares? Dad’s buying!
What the heck! Same day, similar opinion, even a similar title but a different blog:
http://executivephysician.blogspot.com/2007/12/granny-cant-die.html
This paragraph….
“I see the same patient, it seems, several times a day, An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive ciritcal care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient.”
…should be required reading for everyone when they enroll in Medicare. Then there should be a tour through a local nursing home to povide visual evidence that your thoughts are not fiction. Then they should be handed an advance directive and be told to fill it out.
When my mother-in-law was still sentient and capable of making decisions (when she was in her late 90’s), she put into writing her wishes in the event that she became mentally and/or physically incapacitated. She made out a Living Will, signed a DNR, designated my husband as her medical representative, and picked the nursing home where she would like to be warehoused.
When she became both physically and mentally incapacitated (quite suddenly after a fall which broke her shoulder and caused a mini-stroke) we followed her wishes to the letter. She now resides in a warehouse for the elderly (one of the best of its kind, actually), physically is healthy as a horse and takes no medications except Prilosec and Boniva, and is completely demented to the point where she cannot hold a simple conversation because she can’t remember what was said a few second earlier. She doesn’t always recognize her son, or remember me (his wife). She has mostly “good” days, in which she wanders around the home vaguely looking forward to her meals and sleeping 18 hours a day. She rarely has anxiety attacks, which can be resolved by offering her cookies, bright shiny objects, and singing songs with hand clapping..
Mom-in-law is 105 years old. She can’t die, she’s too healthy. Yet, I wouldn’t say that what she’s experiencing is “life”, really…. not what we all call life. She has the occasional slip and fall, and despite her firm written wishes for no extrordinary treatment or resusitation the staff always whisks her off to the ER for a cat scan to see if the fall cracked her skull, and every time she coughs or blows her nose, they call for a wheelchair ambulance to take her to the ER to get her checked out for pneumonia, which she hasn’t had yet. But the trips to the hospital always set her off into terrible long-lasting waves of demented paranoia and fear, and for days after an ambulance ride to the ER she can’t remember her own name and shrinks from all human contact in fear.
Just a few days ago, a nurse’s aid walked into her room just at dawn to bother her with some vitamin or to see if she was still breathing or something, and the rising sun was beaming through the curtains and struck her right in the eyes.
“The Light! The Light!” she shouted over and over. After they calmed her down, it turned out that she believed she had finally “crossed over” and that she was about to walk into The Light and be done with all the misery that her life has become.
So funny, yet so sad at the same time. She’s so healthy that she may go on like this for years before she finally gets to walk into that Light for real.
I found myself hoping for an instant death myself… I can imagine nothing worse than years of extended death in one of these homes. My husband and I made a pact to smuggle each other a fatal dose of heroin or some other kind of opiate if we ever found orselves confined to a bed with a permanent condition like that, so that we could choose to fade out pleasantly instead if endure years if sitting in our own poop while bored aids pushed us around and called us by our first names as if we were children.
Interesting post. Great to read some of the comments about it. I hope we don’t just accept a a broken system and let health care happen to us and our families.
marlene,
The story of your father to me seems a bit unusual because the talk that dominates my doctors lounge is the dissatisfaction, almost loathing, over the fact that our time is dominated providing futile care because family insists on “doing everything”. Most doctor I know don’t like practicing futile medicine. I guess there are some that do.
We could probably all have Cadillac healthcare if as a society we could give up futile care and let people die gracefully. Even though it is the hot topic in the doctors lounge, politicians and policy makers won’t talk about it. It is difficult for doctors to address it because of unrealistic family expectations coupled with a predatory legal environment.
Panda,
The numbers from Braunwald(I could give you studies but I can’t get the copy-paste to work on MEDLINE) indicate that Lives saved at six months for acute PCTA over IV thrombolysis are about 20/1000. This is a similar increase of lives saved for Thrombolysis over placebo. Thus, our wonderful interventional cardiology(when done well,,,,I would be glad to discuss all the caths/stents that DIDN’t need to be done) saves about 40/1000 at six months. That’s 4%, not 100% like you imply. Still, I think that’s worth it and would recommend it to my patients… SO,,,,YOUR POINT about saving granny should be extended to every treatment we do. It’s pretty rare that benefits aren’t marginal. I am taking exception to your KIND of thinking…not the choice you made. I appreciate that you want to consider MARGINAL CARE…It should be considered in every treatment we provide.
For Lisa…
Did you know you can request that your mother in law not be transferred to a hospital.
Ever.
Simple tell the doctor to write an order to make your mother a “no hospital transfer status” and all problems that can be handled in the nursing home will be. All others that can’t will make your mother a hospice/comfort care patient.
It’s as simple as that.
panda, on the whole i agree with you. recently, however, something happened that reminded me we don’t always know when treatment is futile. a 94 year old presented with a perforated peptic ulcer. i told the family that, whichever decision we took, the outcome would likely be the same. however, because of the excruciating pain she was in, i suggested surgery (acid running around your peritoneal cavity is not fun). i operated. she was extubated on the table. she went home after a week. who would have thunk?
Okay, another viewpoint here: I have a child with a life-threatening disease. To maintain his health as best we can, he requires expensive medical intervention daily. With this, he maintains a high quality of life, and is quite bright, a good student, cub scout, etc, and you would never pick him out of a crowd of kids as the boy with a chronic disease. So you maintain that because we as a family don’t have $5000/month in cash to direct to his care we should let him die a slow, painful death, of a disease no one would ever ask for and no one could have predicted he would have? Or does society as a group have a vested interest in allowing him to grow up to be a productive citizen (though possibly needing these medical interventions throughout his life, barring a cure)?
I never said I was against spending a lot of money on medical care. In fact, except for the obvious patients, I support using the full range of medical technology on almost everybody, provided of course that the benefits can be demonstrated and the patient takes some responsibility for their own health (say, quitting smoking after their fourth coronary artery stent).
I’m just pointing out that this sort of thing costs money and there is no magic formula that will make things radically cheaper (unless it were market forces that is).
Unfortunately, there is no incentive to mass-produce a drug to treat an incredibly rare disease. Factor VIII, for example, runs about a thousand bucks for 1000 Units and some patients need 5000 units a couple of times a month for their hemophilia. Nothing to be done but for society to suck up the cost.
But dialysis, pacemakers, and the like for 92-year-old severly demented nursing home residents who have zero, and I mean zero, quality of life? Come on now. Your son has a quality of life and even if he is a bad investment, I look at my tax dollars going to his care as well-spent. Throwing a $20,000 pacemaker into someone who spends their days crapping into an adult diaper, being fed through a tube, and who exists just to be occasionally rolled over in the bed so the decubitous ulcers don’t get too bad is an utter waste and I think everybody knows it.
I was just trying to clarify. I agree with you that there does seem to be a line to draw, but it’s hard to know where to draw it. Huge amounts of care to an elderly patient with no quality of life does seem to be over some line, but what about a patient with a low but existant chance of recovery? Or a child with a chronic disease who is moderately retarded but somewhat functional in daily terms? I’m not trying to be nasty, just to point out that it’s very hard to find exactly where to draw these moral lines, and hard to determine who “should” bear the costs. It’s frustrating for all of us, no question, and debate is always good.
The real debate isn’t that the line needs to be drawn…but who will draw it. We currently have the sacred doctor patient relationship as the source of”rationing”. And I might be appalled at some people’s decisions for their grannie, but we haven’t let “big Brother” draw the line. I think this actually burdens doctors emotionally. It is quite painful for me to sort through my feelings when I find myself at odds with a patients or their family requests. Sometimes having the excuse of “Medicaid won’t pay for that” seems like a easy, but dishonest way out.
There was/is the Oregon Medicaid experiment. That state went through a rationing process in the early 1990’s. Interesting outcome. Didn’t really control costs. Did prioritize some….Made the “rationing” a public discussion…
For an apologetic posting you’ve gotten some interesting responses…
those demented nursing home patients don’t get $20,000 pacemakers, they get $4,000 ones. where do you draw the line?
Amazing analysis. I’ve learned more from your blog than any class in undergrad.
[quote]even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector.[/quote]
The middle aged patient of whom you wrote sounds like my grandfather who died a couple of years before I was born. Everything was fine in the hospital then he died of a heart attack. My dad would be spared this because when he had one, he insisted on staying around the hospital and the doctor did some more tests and found out that he was having one and he was spared. Twenty EXCELLENT years later, he’d die of multiple myeloma. We were upset because the myeloma initially looked like a basic stroke that the doctors didn’t treat– they didn’t realize how active he was with a few dozen horses and told my mom, “He’s old. Old people die.” Six months later, they’d realize what he really had as he wasn’t getting better and was in nursing homes where they didn’t know what to do with him. My learned a great deal of what the health system was about and is now guiding others through it. At first she hated the doctors until she realized that they really wanted to help patients but that their hands had been tied by Medicaid on how they could treat my dad.
A year later, several of my family members are really sick. They are approaching their 70’s and these end of life issues of which you speak are coming up. In a way, I am glad that my dad didn’t outlive his disease– surely this is what he’d be facing. My grandmother keeps getting sick but in that family you don’t let people die.
For years I’d heard that doctors don’t like the “D”eath word. Maybe they have been trained to be scared of it by insurance companies? I don’t know. I can say that I appreciate what you write. You provide amazing topics for discussion and contemplation and you write in a way that can be understood by different levels of education and understanding.
Many of you do not advocate a patient being a “healthcare partner.” However, given a free market ideal, what is a physician or a patient to expect?
Does one question the name-brand medication or procedure recommended by his or her physician or shop around (with the implicit understanding that each and every visit with a PCP or specialist is an additional cost, or one is assigned by an HMO to a physician and must pay out-of-pocket)?
Does one ask a local pharmasist, a friend, or what? Is the patient expected to do so?
It’s one thing to shop around for a can of green beans when one eats them all of the time and has free market access to all of the brands (organic or otherwise), in addition to learning how to grow one’s own, but that free market/individual practice cannot be compared to healthcare.
Honestly, which is it — implicit trust in our doctors that they will save us money and give us correct fiscal advise or become a healthcare partner in a “free market?”
This reminded me of British National Institute for Clinical Excellence (NICE), who decide whether drugs, proceedures, etc, are cost effective enough for the National Health Service to provide for free. They get a lot of hastle from the media whenever they rule against a particular “miricle drug” (which inevitably is no such thing), but they have a simple way of justifying their existance, that is worth quoting: somewhere between the side-effect free miracle drug that costs a pound and gives everybody ten extra years of good quality life, and the drug that costs ten million pounds and gives 5% of the people who take it five extra minutes of life, a line must be drawn.
Does anyone think that it would be practical to sell reduced cost health insurance that does not cover ridiculous end of life heroic measures?
I know that is a very difficult thing to define, but Panda does a good job of describing the multiply co-morbid cases with no quality of life that I am talking about. I am sure that a policy could be drawn up.
I know, absolutely for sure, that I do not want to be kept indefinitely alive with a reducing quality of life, and if I could purchase insurance which was cheaper with that in mind then I would do so. You can be 100% assured that there would be no need for an explicit DNR (or advance directive) if the hospital knew that the patient’s insurance would not pay for heroic measures!
Of course the problem under our current insurance model is that in 30 years I could change my mind and switch to a “full service” plan…. Maybe this does require legislation.
As an aside the European attitude to end of life care is not an accident:
“The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave.”
As you have pointed out, if healthcare is free, everyone wants more of it: that perfectly describes our current American system. For the Europeans the population is paying for healthcare, though taxes, but the GOVERNMENT administers it. Thus the government, the single organization in charge of payment, rigidly define what they will, and will NOT pay for. This reduces the share of GDP (and tax revenues) that medical care consumes, and possibly contributes to a more realistic attitude about end of life care.
I am not suggesting that this is the solution to our current problems, but to act like it is an unrelated phenomenon is not helpful either.
-terry