Right Wing Nut House

We like to think of ourselves as a compassionate people. We also pride ourselves on possessing good old fashioned American common sense.

Those two American traits are on a collision course that, when they collide, will present us with a moral and ethical dilemma that Obamacare is ignoring, and that few of us are thinking about at all.

I’m talking about the stark, and uncomfortable choices we will have to face when our ability to pay for “anything goes” end of life care smashes into our out of control Medicare deficits.

To put it another way, do we bankrupt ourselves, not to save lives but to extend them? Should a 66 year old man suffering from heart disease that will kill him in a year be eligible for a kidney transplant that, if he doesn’t receive the organ, kill him in a matter of weeks?

I addressed some of these issues generally here. The raw data is fairly straightforward. Currently, we are spending $50 billion a year on “end of life” care. A big chunk of that is in hospital stays for dying people who would almost certainly be just as comfortable in a hospice or even at home.

Beyond the question of where a dying American should be treated, there are the painful choices regarding how the patient will exit this world. The problem grows out of the miracles that are routine in American medicine; a drug or a treatment is invented that deals with an underlying symptom of a disease that is killing a patient but has no chance of curing him. The question of whether to grant the dying patient something that will extend life by addressing a health issue that, if not treated, might kill him sooner, while failing to cure his underlying illness is one of those issues that will have to be discussed if we are to both maintain our compassion while trying to solve the fiscal mess that is Medicare.

Obamacare ignores the whole thing - including serious cost containment issues for Medicare of any kind. And it is difficult to see how any serious attempt at “reforming” our medical care system can claim that mantle while allowing these issues to fester.

There are two easy ways out; death panels and giving patients whatever they want. The organization of the proposed Medicare cost effectiveness panel will mandate certain treatments for diseases but will not touch these end of life issues with a ten foot pole. But one could imagine such a scenario occurring in the future if costs continue to spiral upwards.

Obamacare had something of a “fix” for this situation. It gave Medicare the authority to pay for one doctor visit every 5 years where the patients would be informed of their rights regarding what proponents call a “durable power of attorney.” Such a document would specify what kinds of treatments would be acceptable at the end of life, made while the patient was of strong mind and body.

The idea that this would be some kind of effort by the government to force people to euthanize themselves when they get sick is outrageously ignorant. All it does is offer some guidance for your physician those last two month of life. So few of us have these instructions for our physician that right now, the doctor is forced to practice preventive medicine, fearing lawsuits if he doesn’t use the entire panoply of treatments in order to keep a patient going despite the terminal nature of his disease.

Some may wish those extraordinary measures taken. Others wouldn’t. And if we don’t start thinking about it more, we are going to wake up one day where the government is simply going to make those decisions for us.

On my radio show on Tuesday night, we had a hard time coming to grips with the issues involved. I asked Rich Baehr, a health care consultant for 30 years, if one of the problems is that there is the widespread view that health care is a zero sum game, that using resources for those at the end of life takes away from those who need them nearer the beginning. In other words, is there a finite amount of resources available for health care? Even if that is not true, it’s the way that supporters of Obamacare are acting. And if they believe it, then the scenario of government making end of life decisions for us becomes dangerously real down the road.

It needn’t be this way. Part of the solution is almost certainly education - informing Medicare patients of their options regarding end of life treatment and having them plan for that eventuality. Beyond that, it’s a little more complicated; it turns out, that many end of life caregivers believe that nothing short of a revolution in how we view death itself must come about in order for us to avoid both fiscal calamity and decisions at that critical, intimate, and fearful point in life being taken away from us:

Marcia Klish might have lingered for quite some time in the intensive care unit at Dartmouth-Hitchcock Medical Center. But Dr. Byock and his team had a number of meetings with her closest friend, Barbara Menchin. She said Klish would not want to be kept alive on machines if there was no meaningful hope of recovery.

It was decided the doctors would not try to resuscitate her if her condition worsened, which it soon did.

“Her heart has just flipped into a rhythm that doesn’t allow it to beat effectively,” Byock told Menchin.

Klish died a few moments later.

“This is a hard time in human life. But it’s just a part of life,” Byock said.

“Collectively, as a culture, we really have to acknowledge that we’re mortal,” he said. “Get over it. And start looking at what a healthy, morally robust way for people to die looks like.”

Dr. Byok is not a ghoul or heartless monster. He is a compassionate man who is put every day into situations where he knows that, if properly explained, he could ease the passage of his patients considerably. But this is a system that is set up so that the patient has no clue what their true options are and those who might want to spend their final days at home or in hospice are instead, treated to the tune of tens of thousands of dollars of care that has nothing to do with curing what ails them.

By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too.

“I think you cannot make these decisions on a case-by-case basis,” Byock said. “It would be much easier for us to say ‘We simply do not put defibrillators into people in this condition.’ Meaning your age, your functional status, the ability to make full benefit of the defibrillator. Now that’s going to outrage a lot of people.”

“But you think that should happen?” Kroft asked.

“I think at some point it has to happen,” Byock said.

“Well, this is a version then of pulling Grandma off the machine?” Kroft asked.

“You know, I have to say, I think that’s offensive. I spend my life in the service of affirming life. I really do. To say we’re gonna pull Grandma off the machine by not offering her liver transplant or her fourth cardiac bypass surgery or something is really just scurrilous. And it’s certainly scurrilous when we have 46 million Americans who are uninsured,” Byock said.

This is a question I asked in my previous post on this subject:

When a society is faced with a crisis that may lead to its dissolution, is it a higher moral choice to abandon individual ethics and morality to save it? Are we really facing this kind of moral conundrum or am I setting up a “false choice” where another solution is available but I am refusing to acknowledge it?

If we can’t face this issue ourselves; if we can’t come to grips with this delicate and personal issue, then someone is going to do it for us. There’s no continuing the way we are going now.

It’s a pity that in a “comprehensive” reform bill, no mention is made of these vital and complex issues.