‘THE COST OF DYING:’ FALSE CHOICES OR THE FUTURE OF AMERICAN HEALTHCARE?
I watched this 60 Minutes segment last night on “The Cost of Dying” with extraordinarily mixed emotions. From anger to fear to horror, I have rarely had such an emotional reaction to an issue.
But once past the knee jerk outrage, I began to assess the moral and ethical dimensions of the problem and am extremely unsettled in where these questions lead me.
Some background on the segment:
Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients’ lives - that’s more than the budget of the Department of Homeland Security or the Department of Education.
And it has been estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.
You might think this would be an obvious thing for Congress and the president to address as they try to reform health care. But what used to be a bipartisan issue has become a politically explosive one - a perfect example of the costs that threaten to bankrupt the country and how hard it’s going to be to rein them in. Dr. Byock leads a team that treats and counsels patients with advanced illnesses.
He says modern medicine has become so good at keeping the terminally ill alive by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily.
“Families cannot imagine there could be anything worse than their loved one dying. But in fact, there are things worse. Most generally, it’s having someone you love die badly,” Byock said.
Asked what he means by “die badly,” Byock told Kroft, “Dying suffering. Dying connected to machines. I mean, denial of death at some point becomes a delusion, and we start acting in ways that make no sense whatsoever. And I think that’s collectively what we’re doing.”
Now for the moral questions raised by the piece; How much do we, as a society, value individual life? At what point does what’s good for the many outweigh what’s good for the one? Should anyone - insurance companies, government, or a “death panel” - have the right to tell a patient and their family when it is time to let go of life and allow the natural progression of their disease to kill them?
All of these questions and more like it are asked with the costs associated with end of life treatment always in the background. And it isn’t just the costs. It is the tremendous amount of health care resources devoted to people who have no hope of recovery but make choices like this patient:
Charlie Haggart is 68 years old and suffering from liver and kidney failure. He wants a double transplant, which would cost about $450,000. But doctors have told him he’s currently too weak to be a candidate for the procedure.
At a meeting with Haggart’s family and his doctors, Dr. Byock raised the awkward question of what should be done if he got worse and his heart or lungs were to give out.
He said that all of the available data showed that CPR very rarely works on someone in Haggart’s condition, and that it could lead to a drawn out death in the ICU.
“Either way you decide, we will honor your choice, and that’s the truth,” Byock reassured Haggart. “Should we do CPR if your heart were to suddenly stop?”
“Yes,” he replied.
“You’d be okay with being in the ICU again?” Byock asked.
“Yes,” Haggart said.
“I know it’s an awkward conversation,” Byock said.
“It beats second place,” Haggart joked, laughing.
Should someone make the decision to resuscitate this gentleman for him? Who?
This is what end of life caregivers are asking these days. And the solution, in an echo of Sarah Palin’s “death panels,” may be hard and fast rules on what kind of care the terminally ill can demand of the system:
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.
Is Byock a ghoul? Or is he talking sense? This is a compassionate conflicted man if you watch the segment. The chasm he has opened beneath our feet is both a moral and practical one and the tightrope he is asking us to walk is very thin indeed. If we decide to take these circumstances and apply universal guidelines for the treatment of the dying, won’t individuals “slip through the cracks” and be condemned to die who might otherwise outlive a doctor’s expectations with treatment? How many people who are given 2 months, three months, six months to live end up amazing their physician by surviving for years?
And then there’s the question of resources devoted to the dying. Here’s a Dartmouth researcher who did a detailed study on patients in the last two years of their lives:
The institute did a detailed analysis of Medicare records for patients in the last two years of their lives. Fisher says it is more efficient for doctors to manage patients who are seriously ill in a hospital situation, and there are other incentives that affect the cost and the care patients receive. Among them: the fact that most doctors get paid based on the number of patients that they see, and most hospitals get paid for the patients they admit.
“The way we set up the system right now, primary care physicians don’t have time to spend an hour with you, see how you respond, if they wanted to adjust your medication,” Fisher said. “So, the easiest thing for everybody up the stream is to admit you to the hospital. I think 30 percent of hospital stays in the United States are probably unnecessary given what our research looks like.”
[...]
“In medicine we have turned the laws of supply and demand upside down,” Elliot Fisher said. “Supply drives its own demand. If you’re running a hospital, you have to keep that hospital full of paying patients. In order to, you know, to meet your payroll. In order to pay off your bonds.”
And, of course, the fact that these costs are rising at a frightening pace is also driving the debate over end of life care:
“The perverse incentives that exist in our system are magnified at end of life,” David Walker, the government’s former top accountant told Kroft.
Walker used to be the head of the Government Accountability Office. He now heads the Peter G. Peterson Foundation, which is a strong advocate for reducing government debt. He says that 85 percent of the health care bills are paid by the government or private insurers, not by patients themselves. In fact most patients don’t even look at the bills.
“Does that make any sense to have, I mean, most things you buy, the customer has some impact,” Kroft remarked.
“We have a system where everybody wants as much as they can get, and they don’t understand the true cost of what they’re getting. The one thing that could bankrupt America is out of control health care costs. And if we don’t get them under control, that’s where we’re headed,” Walker said.
What all of this adds up to is that America is headed for the most difficult ethical and moral dilemmas in its history - questions that go to the very heart of what our country stands for, how we see ourselves; questions that deal with our deeply held religious beliefs, and perhaps most uncomfortable of all, cultural questions about the nature of life and death.
In all of this, the individual, and choices they have been able to make in the past about how they wish to exit this world, may very well be taken from them for the “good of the many.”
(Note: I hasten to add that there is nothing in either the Senate or House bill that directly deals with these questions, although the Medicare Cost Control panel certainly has that potential.)
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?
I would like to think I have fairly presented the questions asked in the 60 Minutes segment. My personal belief is that the issues raised are impossible to discuss at this point because of the debate over reform and the political ramifications of discussing end of life treatment that would necessarily play into the fear mongering that arises whenever “unplugging grandma” is mixed in.
Here’s Doctor Byock on that subject:
“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.
One thing that can be done was removed from the House bill because of Palin’s fearmongering; family doctors being paid to sit down with their Medicare patients to discuss living wills, end of life options, and educating their patients on the death process. The number of people who are unaware of these simple, common sense options are staggering. The idea that this is somehow cruel or would lead to doctors recommending that patients simply allow themselves to die was idiotic when the argument was made and, if you watch this segment closely, even more idiotic now.
A word about “rationing” which is the 800 lb gorilla in the room that I have avoided because of the idea that many opponents of health care reform can’t face the fact that we are already rationing resources. What’s interesting - and gives a depth of understanding to the moral dilemma we face - is that according to the Dartmouth study, rationing would be unnecessary if we dealt with end of life issues:
After analyzing Medicare records for end-of-life treatment, Fisher is convinced that there is so much waste in the present system that if it were eliminated there would be no need to ration beneficial care to anyone.
Multiple studies have concluded that most patients and their families are not even familiar with end-of-life options and things like living wills, home hospice and pain management.
“The real problem is that many of the patients that are being treated aggressively, if you ask them, they would prefer less aggressive care. They would prefer to be cared for at home. They’d prefer to go to hospice. If they were given a choice. But we don’t adequately give them a choice,” Fisher said.
“At some point, most doctors know that a patient’s not likely to get better,” Kroft remarked.
“Absolutely,” Fisher agreed. “Sometimes there’s a good conversation. Often there’s not. You know, patients are left alone to sort of figure it out themselves.”
I can’t stand people who approach these issues as if there is no real moral or ethical dilemma; that people should either be forced to die or that they should get any care they wish in order to hang on to life even after hope for recovery has expired. We are fast approaching a time when we will forced to make this choice and there is nothing easy or pat about it.
Those so certain of the moral ground beneath their feet are oblivious to the fact that they are really standing in quicksand. And their arrogant certainty about right and wrong is exposed as the sophistry it truly is.
Living wills and advanced directives. A living will allows a person to state exactly what level of end of life care they want. Everyone should have one. My wife of 25 years was diagnosed with bile duct cancer and lived just 3 months after the diagnosis. We had doctors coming out of the woodwork to offer tests, pain relief surgery, breast exams, pap smears, and on and on after she was clearly not going to live much longer and was settled in her mind about the terminal diagnosis.
I would have paid any price to get her better, but there was no chance of that. She chose death with dignity and made peace with every important person in her life before letting go of life.
Everyone can make their own choices about end of life care. Death is a natural part of life and no amount of money, compassion, guilt or anything else will change this basic fact. The cost of end of life care is a major issue and working with individuals and families in making these decisions must be a part of health care, regardless of any or no changes in provision of care. Hospice, or palliative care is an essential service and it is much more humane (and cost effective) than throwing services at dying people that make no difference, but are authorized by our current insurance system.
There is not a system on the planet that does not “ration” health care in some manner. Do it thoughtfully and carefully.
Sorry for your loss.
We have to have a fundamental change in the way our society deals with death. That is the unstated lesson I draw from this. It can be done if most people take advantage of the same things you and your wife ended up embracing. But apparently, the vast majority are unaware of these options and therefore go into the final stages of life in fear and ignorance.
ed.
Comment by still liberal — 11/23/2009 @ 11:44 am
And yet that’s the box we’re in.
Democrats (from their perspective) tried to do the right thing on gun control for 25 years. The minute we said the hell with it, let them keep their damn guns we started winning elections.
Perhaps Obama in 2014 can do something, but it means the Democrats and the Republicans are going to have to hold hands and jump off the bridge together. As long as we have “Death Panels” and concentration camp talk from the adorable Sarah Palin and Michelle Bachmann, things won’t move an inch. But you know you’re self you are as much pi**ing in the wind in this one.
Not if in another decade these decisions will be made for us by out of control budgets and massive debt.
ed.
Comment by Richard bottoms — 11/23/2009 @ 11:47 am
Sharp piece.
This is the Achilles Heel of national health care, isn’t it? For a myriad of reasons, it is more jarring to have the state make the decision regarding rationing than private concerns.
We really aren’t talking about advance directives and powers of attorney for health care here (both excellent and recommended ways for private individuals to have a degree of autonomy; I couldn’t agree more with what was written in the previous comments). We are talking about the rationing that now happens on a private basis being dictated by the government. For the same reason I feel uneasy about the death penalty, I also dislike when the state exercises life and death decisions about health mattes. Like you, I don’t know where to come down here.
Comment by jackson1234 — 11/23/2009 @ 11:55 am
The dilemma facing anyone with an end-of-life decision is one that beggars the imagination. If you have not gone through it yourself, you cannot know the agony associated with the situation.
Two examples in my own family. One is an uncle who was given a medical death sentence - Stage IV renal cancer with less than 6 months to live. He chose ot avoid the potentially life extending chemo and radiation treatments because they may extend his life by a few months but the pain of going through either would be excrutiating. He chose a homeo-pathic regime of vitamins and herbal treatments. That was 14 years ago and he is still alive and kicking - and even more importantly he is enjoying life. Twice he has gone back to doctors to see if his condition has changed and in both instances the doctors just shook their heads and told him he still had but 6 months left at most. The last time he did this was 4 years ago.
The other case was my mother. In January she went into the hospital for a routine series of tests and five days later was gone.
I do not have an answer for society at large. In cases like this, I tend to defer to the family and their doctor. I just hope any resultant reforms that come from the current legislative efforts keep it at that level. It may be easy to put the medical problems we face in a dollar and cents manner, it is another thing altogether when the dollars society may be saving seemingly condemns someone you love to their demise.
Comment by SShiell — 11/23/2009 @ 11:56 am
I happen to think Mr. Obama’s cautious nature is an indicator that he will turn his attention to the problem once we’re past the current HCR debate, the terror trials, DADT, and a jobs recovery. Or, in other words in his second term.
BTW, if you are in the mood for deep thoughts about large institutions you have to read “Wired for War”. There are some radical changes (should I use that word?) that have to happen with the US military as well.
Robotics, cyber-warfare, drone technology, and human engineering and leading towards a massive shift in war fighting that at the moment we are on the wrong end of.
Take for instance, do we build Skynet accidentally by meshing our battlefield robots with cellular technology? Do we need to be thinking about the Three Laws now?
Scary stuff, and even scarier China is miles ahead of us, not in planes or tanks but engineers and robotics expertise. The theater of war for 2025 will be vastly different and we aren’t prepared.
Yet.
Comment by Richard bottoms — 11/23/2009 @ 12:22 pm
the more you stick around on Earth the more you know this is (and always will be) an intense and personal decision. Fear of death is part of human nature and strangely is exacerbated by rising life expectancy. Every one of us probably has had multiple experiences in their immediate and extended family.
However, as a young kid it always impressed me to hear of the inuit (eskimos) back then. When they were a burden to everyone else they just snug out into the snow storm to save the rest. I always thought ‘would I have the guts to do the same’. I don’t want people to misunderstand and think I’m in favor of ending ‘unproductive lives’. At the same time, we as a society can’t commit financial suicide and we have to find a way, very delicately and very careful. This is really not topic for politics as usual.
Comment by funny man — 11/23/2009 @ 1:03 pm
@jackson1234:
“This is the Achilles Heel of national health care, isn’t it?”
No. This is the Achilles Heel of health care, regardless of who pays the bill.
If you’re indepentdently wealthy, you can spend whatever you like to get whatever treatment you like. If you are one of the other 99.99999999% of the population, you get the care your provider will pay for. Whether that provider is the government or United Healthcare . . . there is a limit.
There can be no (real) debate as to the moral quagmire end-of-life care represents when it comes to potential-vs-practical treatment. I’d love for everybody to get all the care they want, but the world doesn’t work that way. That problem, however, isn’t an issue with healthcare reform, but a simple matter of supply and demand. Reform healthcare, don’t reform healthcare . . . the problem will remain the same.
I would be overjoyed if this country actually bit the bullet and tried to deal with this ethical problem head-on. Sadly, I doubt we will. There is no “good answer” to this problem, and so we are probably going to do what we always do as a society when faced with a painful choice — avoid it. Far easier to just complain when someone can’t get the care they want, or when someone uses up care that could have saved someone else because they were selfish and greedy. Easier to complain about a wrong that has happened than to suffer proactively. Infantile, shallow, and weak . . . but easier.
Comment by busboy33 — 11/23/2009 @ 1:16 pm
“I happen to think Mr. Obama’s cautious nature is an indicator that he will “avoid the very mention of the problem” once we’re past the current HCR debate, the terror trials, DADT, and a jobs recovery.”
There, fixed it!
And regarding: “Or, in other words in his second term.”
Care to make a wager?
Comment by SShiell — 11/23/2009 @ 1:31 pm
Wow.Cogent writing. “Right Wing Nuthouse” on the header had me cringing.
Spot-on analysis. Let the discussions begin!
Comment by FlynnMD — 11/23/2009 @ 1:35 pm
“For a myriad of reasons, it is more jarring to have the state make the decision regarding rationing than private concerns.”
Why? Why is it more jarring for a bureacracy make this decision, than an insurance company?
I agree with Rick’s sentiment, that this is an agonizing and complex issue, and Richard bottoms comment that right now our national debate is so filled with wild theatrics and scare tactics, that reasoned discussion is nearly impossible.
Comment by Liberty60 — 11/23/2009 @ 1:38 pm
IMO most people do not want to have this conversation and will not have it. If they are covered (privately or through medicare/medicaid), those folks will take what they can get. If they are not, they’ll do the same but what they “get” will be very little. I don’t see how you can get these folks to engage. I think government regulation is the only way to spread the limited resources in an equitable fashion. At least that way all are included and have some input.
Unfortunately my position is interpreted as wanting to “pull the plug on grandma”.
Comment by HyperIon — 11/23/2009 @ 2:01 pm
“Those so certain of the moral ground beneath their feet are oblivious to the fact that they are really standing in quicksand. And their arrogant certainty about right and wrong is exposed as the sophistry it truly is.”
How true, see
ttp://michellemalkin.com/2009/11/23/demcare-dunce-of-the-day-sen-bennet-says-hell-sacrifice-job-that-hes-already-losing/
Oh wait,wrong party.
RM you are a fool.
Got it all figured out, huh? Good for you. And don’t let all those people laughing at you get you down. I admire someone who is oblivious to how full of shit they are.
And btw, the next time you email my boss about why he should fire me - something we both got a good laugh about - I will make it a point to find your real name (coward) and place of employment and see how your boss feels about you playing on the internet when you’re supposed to be at work.
ed.
Comment by MooseH — 11/23/2009 @ 2:02 pm
It was my sincerest hope that somewhere in the Healthcare reform “debate” we might, as a nation, at least start to have the discussion about end of life care and options beyond staying (and dying) in a hospital: hospice and palliative care, for example. I have no real hope that will happen anytime soon, since so many people seem to be intellectually and emotionally 12 years old. (Sex is just as natural a part of life, yet we cannot even have a discussion about it without about 60% of the population having an apoplectic fit….)
The only thing that gives me pause is that the realities of our aging population will intrude and we will HAVE to have this conversation. And, as others have noted here, the financial aspects will be unavoidable as well.
I would hope that during this shift in thinking that the contributions of counselors and hospice workers might get more support than they currently receive. Those folks are truly doing the work of the Lord. It’s just too bad they don’t get paid for it.
Comment by Marge Gunderson — 11/23/2009 @ 2:17 pm
Part of the problem is that there is no single answer. For some people, “the problem” is getting
as much care as they can. For others, “the problem” is avoiding meaningless and painful tests and treatment and making personal peace with their imminent mortality while medical establishments try frantically to run up billable procedures. Is the problem “death panels” or “life panels”? I’m not sure this is even something “we as a society” can address.
I don’t think we’re going to have a choice whether we want to address the questions raised or not. We will go bankrupt - no joke, not figuratively, not scare tactics but honest to God flat busted broke - if we don’t figure it out.
ed.
Comment by Roberta — 11/23/2009 @ 2:20 pm
And I applaud Dr. Byock’s guts in his answer about what is scurrilous. Would that even one person inside the beltway had said the same thing about six months ago.
Comment by Marge Gunderson — 11/23/2009 @ 2:21 pm
Roberta - “we as society” means each of us, individually, talking with our families, our church, our communities.
Certainly we can all have THOSE conversations.
Comment by Marge Gunderson — 11/23/2009 @ 2:23 pm
There are two issues that get tangled together here and should be seen separately.
First, the amount and kind of care for a person certain to die soon. The problem to be confronted there — who decides when death is a certainty — is ethically dicey but not practically complicated.
Second, when is it right to provide advanced treatment for a person quite old or very sick that will be expensive but may be life-saving in that it provides a significant extension of life — and who decides that. This is a much tougher question that cannot properly be dealt with by reference to average ages or average lifespans for people with a similar ailment.
The two are almost always rolled together with those statistics about the cost of care in the last two months of life. Except in the case of murders and suicides, and some sudden fatal heart attacks, the most extensive and expensive care is bound to be delivered in those last two months, because that is when a person is the most seriously ill. But to what should such a stat be compared? Should it not be compared to the cost of care for someone equally ill or equally old or both over a two month period who recovered and lived a good deal longer?
My mother dies at age 80 of post-operative complications of surgery to replace her aortic valve. She had been hospitalized repeatedly in the months prior to the surgery. She face death within a year without the surgery and the prospect of five or more additional years with it. She took the risks inherent in such surgery at her age and condition. The operation was a success, but a few days later, she acquired an infection which became systemic sepsis and died after about 1o days in an IC unit of one of the nation’s leading teaching hospitals.
Between the pre-surgery hospitalization, the surgery and post-surgery IC care, I’ve no doubt that her two-month bills amounted to the largest health care expenditure of her lifetime. Her case added to those seemingly ominous two-month stats. But Barbara Bush, I believe, had the same surgery at about the same age not long ago. So far as I know, Mrs. Bush is going strong and may well live that extra five years the eluded my mother.
So aren’t those two case a trade off, just as herioc care for two youinger accident victims might result in one saved life and another lost?
Comment by John Burke — 11/23/2009 @ 2:30 pm
“Got it all figured out, huh? Good for you. And don’t let all those people laughing at you get you down. I admire someone who is oblivious to how full of shit they are.”
“And btw, the next time you email my boss about why he should fire me - something we both got a good laugh about - I will make it a point to find your real name (coward) and place of employment and see how your boss feels about you playing on the internet when you’re supposed to be at work.”
Sounds like a an Obama Chicago thug instead of that thoughtful,intellectual you want us to believe you are.Your true colors are beginning to show.
Does your boss know you are responding on your private website during your working hours?
Are you threatening me?
A threat to expose you? You betchya. That’s the only way to deal with cowardly mountebanks like you.
And which boss are you talking about? You don’t have a clue what my working arrangements are.
ed.
Comment by MooseH — 11/23/2009 @ 2:38 pm
Even the Catholic Church does not insist on “heroic” measures. That would be my guide. I have had a good life and a life filled with laughter and love. And I think what it comes down to is one’s belief structure. I believe that I will be going to a better place, a higher existence - so death is not frightening to me. And on some mornings, when the arthritis in my spine is especially intrusive, it is almost but not quite attractive to me. But I realize that there are still things I want to accomplish and a beloved cat to care for (nobody else would want him - he has a somewhat tetchy disposition - kind of like me) so I take my tylenol and soldier on. But at 67 years of age, I see the finish line in sight and it doesn’t worry me much. Just don’t want to kick with a dirty kitchen is all!
Comment by Gayle Miller — 11/23/2009 @ 2:40 pm
John Burke - you hit the nail on the head.
Situation one should not be difficult to discuss. I’m afraid it will be, because too often it morphs into situation two - witness the guy on the 60 Minutes show, who, at 68 and already quite ill, wanted a double transplant. A DOUBLE TRANSPLANT. I’m 41 and pretty healthy, and I’m not sure I would be up to that. As it happens, the show said he didn’t get it, and died a few months later, of the original problems that led him there. He was never well enough to even get the transplants.
Personally, I think doctors need to be more realistic with people and their chances. And I totally get the 500 reasons why they aren’t, but perhaps if individuals and their families insisted on some more candid talk, it would happen.
Comment by Marge Gunderson — 11/23/2009 @ 2:46 pm
I was taken back 22 months to that same ICU complex in Dartmouth Hitchcock where my father spent his last moments. The doctors offered us many procedures, but little hope.
And so, rather than let him suffer, and despite his whispered plea that he didn’t want to die there, we had no options offering any “quality of life.”
At the heart of the matter is the following….medical technology can keep a broken body pumping blood infused, artificially, with oxygen, but the body fails in the end.
How do you want to die? Think about it. We all will die, and I have no wish to hurry it along, but is life without quality truly living? If you cannot recognize your children because you are in a drug induced coma so that you don’t fight the machines, is that really living?
Of course, some would say yes, and I respect that, but durable powers of attorney and living wills do little to answer that question. They deal with brain death and no hope of survival. But what of just being worn out? And, honey, we’re all going to wear out!
So I leave you with this. Talk about it. Talk about it before it’s too late. It’s painful, but the alternative, trying to remember snippets of conversation about not wanting to live if you can’t enjoy life….THAT is painful. Talk about it, and talk about it with the people who matter to you.
Once you’ve done that, then write it down. There are many ways to die. And if you can’t speak to your wishes, you will need trusted family and friends to do it for you.
Talk about it.
Comment by Jay — 11/23/2009 @ 2:59 pm
I have almost never seen this kind of honesty in someone who isn’t in healthcare. I’m a hospital Chaplain and walk people through these decisions daily. The way we handle death in our ICUs is dastardly and a product of a rabid denial of mortality.
Comment by frostbite — 11/23/2009 @ 3:32 pm
busboy, Liberty60:
I couldn’t disagree with you more. Any time the state gets involved in end of life decisions, whether it be Terri Shiavo or putting a criminal to death, it adds an “X” factor that should disturb you as well. This really isn’t political with me. But it will become political or at least more political if government acts in locus parentis on such personal matters. Granted, government involvement may be unavoidable, but you shouldn’t see this through some black and white prism, “government good, health insurance bad.” It is disturbing any time government takes life, either passively or intentionally, whether that is war, execution, or termination of health services.
Comment by jackson1234 — 11/23/2009 @ 4:23 pm
Jackson:
If someone else is making a decision on when I need to die and I have the following choice of decision-maker:
a) A guy who will make more money and have more job security if I die fast and cheap.
b) A politician who may want my family and friends to support him in the next election.
I have to go with (b.) You really don’t want to leave that decision in the hands of someone whose stock options rise in value if you die.
Comment by michael reynolds — 11/23/2009 @ 5:11 pm
Michael Reynolds:
or, c) as it exists now with Medicare: a governmental paper pusher with a mandate to provide care and no regard to costs whatsoever.
Wish I could get that kind of coverage. Guess I’ll have to wait until I’l 65.
Comment by Marge Gunderson — 11/23/2009 @ 5:21 pm
On the larger issue, I would love it if we had an intelligent conversation in this country. Unfortunately it will quickly devolve into a competition between political parties over which can swear the greatest loyalty to the elderly.
Old people vote. Which is why the government will buy a transplant for a 100 year-old man, but tell a twenty-five year old to drop dead. And it’s why paranoia about the government and death panels is so ludicrous. You’ll note that we are now debating whether to extend to young people the very benefits we long since granted old people.
I’ve had a living will for more than a decade, ever since our first kid was born. Had it updated not long ago. It’s a fairly grisly discussion (So, let’s say you’re in a coma, is it okay if we starve you?) but really if you’re old enough to make the old man grunting noise every time you stand up you’re old enough to face the fact that the death rate is still right where it’s always been: 100%.
It’s staggering in a country full of people who claim to believe death is just a ticket to eternal life that people are such pussies about death. When I die I expect I’ll cease to exist. (By the way, I answered, sure: starve me. At least I’ll die thin.) So why is it I can face it more easily than all the paradise-bound Christians?
Comment by michael reynolds — 11/23/2009 @ 5:26 pm
Interesting comments all.
Michael, do you also want a politican who knows he won’t get your vote to make your health care rationing decision? You can rest assured that it also will be “profit,” i.e., political support, that drives all rationing decisions (it does today; Medicare cuts for the elderly in their end of life are non-existent while Medicaid cuts for productive citizens are much more routine largely due to the influence of the AARP and the political awareness of older voters). My guess is the quest for power will even trump the Almighty Dollar–to the extent there is any difference between the two–in such decisions.
And isn’t it telling that even before we know whether there will be a healthcare bill the discussion immediately proceeds to rationing? Palin’s “death panel” remark suddenly doesn’t seem as hyperbolic as it did way back when it was made–July, I think.
My biggest concern will be when pols decide the liver transplant for a five year old is more important than a knee replacement for a 40 year old laborer because the kid’s parents donate to Party or Person X. Obviously there is rationing now and will be in the future, and there needs to be limits to end of life care, but the thought that raw political calculations and opportunism will inform healthcare decisions scares the shit out of me.
Comment by obamathered — 11/23/2009 @ 5:35 pm
I didn’t see you addressed the point before I posted, Michael. I largely agree.
Comment by obamathered — 11/23/2009 @ 5:37 pm
Michael,
to answer your last question: because talk is cheap. How much people really believe, how much they fear death is a topic most don’t like to deal with. Sometimes I’m forced to deal with it but it is not comfortable. Yes I can talk about it with other but I remember a very moving painting by Frieda Kahlo after her miscarriage in Henry Ford hospital in Detroit basically showing ultimately you have to bear the pain, the fear and uncertainty alone. Comforting to know this is a common bond between us mortals (smile)
Comment by funny man — 11/23/2009 @ 5:47 pm
@jackson:
“but you shouldn’t see this through some black and white prism, “government good, health insurance bad.””
I agree entirely, but I don’t see how I’m saying that. In regards to the topic-at-hand with this thread (limits and controls on end of life acre issues), I said that whether we were talking about government funded health care of privately funded health care, the crux of the dilemna was identical. How is that favoring one over the other?
If the topic is strectched to health care reform in general, as I’ve said in prior threads I’m not for government healthcare instead of private healthcare . . . I’m for government healthcare instead of NO healthcare. The main goal with the reform movement was (in my eyes) to get coverage to the uninsured and to prevent private insurers from denying coverage to those that should be covered. While the government may have a demonbstrated track record of incompetence, they also have a track record of not being profit focused (for better or worse). Private insurance has a track record of denying/excluding coverage if it financially benefits them, regardless of the detriment to the patients. Of those two options, I choose government incompetence.
As I’ve said before, I’d rather perfect private healthcare . . . but that is demonstrably not going to happen.
This seems to be something conservatives don’t understand. I can’t speak for a ll liberals, but THIS liberal isn’t in favor of government controling all aspects of mny life . . . but I AM in favor of certain minimum things (like healthcare) that, if the private sector can’t/won’t resolve, then the government will have to do it. The government generally doesn’t pass laws because its bored. It doesn’t regulate things because they enjoy it. They do so in most cases because the private sector failed to handle it themselves. Auto regulations? “Unsafe At Any Speed”. Food safety regulations? Upton Sinclair. Workplace Regulations? Sweatshop conditions and “yello dog” employment contracts. These rules came from somewhere, and there was a pressing need for them.
It’s a shame that the government has to act in loco parentis . . . but if the kids are all behaving badly then somebody has to impose some friggin order. You mentioned Schiavo. The government didn’t declare what to do — the court just said that the husband’s version of what she wanted was more credible than what her parents claimed she wanted. They didn’t dictate the care she received — Terry Schiavo did. Someone had to referee that fight because the parents and the husband wern’t going to agree on their own.
THAT’s what government is for.
Comment by busboy33 — 11/23/2009 @ 6:34 pm
busboy33: well said.
I’m stealing “government healthcare instead of NO healthcare.” That’s a great line and puts the whole thing in perspective.
It’s what I’ve been trying to tell my RW relatives for some time now - why can’t I sign up for SOMETHING that doesn’t cost $1000 a month, (or more) in case I lose my job? Why couldn’t I have Medicare for $96.40 a month, temporarily, while I look for a job? I would gladly pay that rather than worry that I might lose everything I own because I’m “not covered” and something happens.
Comment by Marge Gunderson — 11/23/2009 @ 6:55 pm
Michael Reynolds said:
Exactly this. Well said.
Comment by Chuck Tucson — 11/23/2009 @ 10:27 pm
When my greataunt was 89, her hip broke and she fell. The young surgeon wanted to operate, give her an artificial hip. Fortuneatly her doctor was almost her age and put his foot down. He felt she probably would not survive surgery so nothing was done. She lived several more years without constant pain and died peacefully.
My life partner was subjected to a series of useless surgeries at the end of his life. The surgeon just kept cutting away, prodding him to moan and then saying the patient wants this. More money on useless procedures in the last 3 months than in the previous 5 years of successful treatment.
The term missing from this discussion is ‘managed condition’. Some conditions can be managed for a long time, some can’t. Need to see how to manage a patient’s condition as death approaches.
Comment by dalea — 11/23/2009 @ 10:48 pm
Tuesday morning links…
I’ve been slow to realize this: the O is turning out to be a dud. I did not vote for him, but I had some hope that he would try to govern as a pragmatist-moderate - against all evidence, of course. Even the thrill is gone for Chris Matthews.
Newt q…
Trackback by Maggie's Farm — 11/24/2009 @ 4:47 am
[...] will want to read Rick Moran’s commentary. He isn’t the only one who finds this chilling. I’ve come too close to comfort to [...]
Pingback by “Pulling the Plug on Grandma” : The Pink Flamingo — 11/24/2009 @ 6:26 am
Doctors can’t do this unless the governments involved? The issue that Palin raised is that the government should not be setting up any standards or ‘recommendations’ which doctors adhere to in dealing with end of life decisions. If doctors need the government to do their job - and I don’t see why a doctor cannot raise these issues during already occurring visits with a patient - then we’ve got bigger problems that cost of healthcare.
The “involvement” of government was that Medicare would pay for the doctor’s visit - once every few years. That’s it. Period. No instructions to the doctor to tell them how to advise their own patients. No death panels. It was pure fear mongering and a bogus, fallacious slippery slope argument.
ed.
Comment by Bald Ninja — 11/24/2009 @ 7:03 am
michael reynolds Said:
5:11 pm
If someone else is making a decision on when I need to die and I have the following choice of decision-maker:
a) A guy who will make more money and have more job security if I die fast and cheap.
b) A politician who may want my family and friends to support him in the next election.
I have to go with (b.) You really don’t want to leave that decision in the hands of someone whose stock options rise in value if you die.
Yeah - we’ve go to keep an eye on those foot-rustling, tonsil-digging doctors. Good thing we’ve got the compassionate government bureaucrat in our corner! /SARCASM
Comment by Bald Ninja — 11/24/2009 @ 7:08 am
I hope that our government bureaucratic healthcare overlords are more compassionate than you.
Comment by Bald Ninja — 11/24/2009 @ 7:11 am
Ninja:
What does a will or a living will have to do with compassion? Or a government overlord?
Look, you find a form online, or you go to your lawyer, and you answer a bunch of difficult questions. And then when you get sick or die you don’t shove all the decisions off on your wife or your kids.
The lack of compassion is shown by some 90 year old bankrupting his family so he can cling to life for an extra two weeks. Or forcing his distraught family to argue and fight over what his wishes might have been.
You’re going to die, Ninja. We all die. So take an afternoon and do the grown-up thing and work out a living will and a regular will.
Comment by michael reynolds — 11/24/2009 @ 9:07 am
Well one thing I haven’t yet heard mentioned (though I may have missed it) is that these choices are made difficult by the fact that the ones making the decision aren’t the ones paying the bill. Would a 90 year old opt for a $500,000 surgery that might give her a few more months of life while crippling her family financially for the next 10 years? Probably not. But of course in most cases neither the grandma, nor the family is paying the bill so everyone gets to complain about heartless insurance company bureaucrats saying no when they’re really doing it so we won’t have to.
Comment by theblackcommenter — 11/24/2009 @ 10:07 am
Everyone should have a living will and deside before had how they want to be treated when they get seriously ill. I don’t want doctors to just keep me alive with no hope of recovery.
Example: About 20 years ago my mother’s aunt was ill and going to die. Two doctors want to operate on her to maybe let her live a couple more months. My mother said no. These two doctors went almost nuts, how dare you question us- we’re Gods. Of course, these two doctors knew insurance was going to pay the bill, not my parents.
Comment by meanjoegreen59 — 11/24/2009 @ 10:10 am
I’m support people getting living wills and dealing with end of life issues before the end of life approaches. My snark was mostly in reference to your trust of government over doctors and you’re only angry display at those who’ve chosen not to do what you have done.
What I don’t support is putting this sort of planning - or ‘encouragement’ of planning - in the hands of government. Doctors don’t need laws to tell them to encourage patients to do this and laws shouldn’t exist forcing people to do this.
Comment by Bald Ninja — 11/24/2009 @ 10:41 am
Medicare doesn’t already pay for a doctors visit for any reason? A doctor can’t spend 10 minutes talking to a patient during a yearly exam?
It concerns me when a bill has to micro-manage things at this level.
Comment by Bald Ninja — 11/24/2009 @ 10:44 am
What I don’t support is putting this sort of planning - or ‘encouragement’ of planning - in the hands of government. Doctors don’t need laws to tell them to encourage patients to do this and laws shouldn’t exist forcing people to do this.
The existing “law” for doctors is the law of the free market. They make money from performing procedures. So what exactly would motivate a surgeon to say, “Look, you don’t need or want this surgery, all it would do is drag out your miserable existence for another six weeks.”
Why would a surgeon say that to a patient? Altruism? Are you a big believer in altruism? Because I have to tell you that the predicate of a free market is individuals acting in their own interests. It is very much in the surgeon’s interest to perform surgery. And there is really zero doubt that health care in this country is about ass-deep in unnecessary but very profitable procedures.
Unless you propose eliminating Medicare the vast majority of these pointless but very profitable procedures are going to be paid for by the taxpayer. So don’t you think it’s a good idea for the persons paying — the government, meaning us — to have some say in how many pointless procedures a doctor performs? Or is your wallet just an open trough at which any doctor may feed?
Comment by michael reynolds — 11/24/2009 @ 11:02 am
If you read the actual posts on Sarah Palin’s FaceBook notes page (you won’t get cooties if you go there, I promise), you’ll realize that the claim she was targeting the ‘end of life discussion’ provision is a stretch. Tagging her with opposing Section 1233 was an attempt to make her position seem unreasonable when she was actually complaining about the comparative effectiveness reviews that are already in action (they were funded as part of the ‘porkulus’ bill). Those are the ‘death panels’ that under a single-payer scheme would decide the protocols for who is given what treatments.
She was also far from the only one raising questions about the provision. Noted snowbilly fear-monger Charles Lane of the WaPo wrote an op-ed pointing out the problem of simultaneously paying doctors to counsel patients on living wills, etc while at the same time grading them their ‘effective’ use of medical resources.
Comment by DerHahn — 11/24/2009 @ 11:35 am
Michael Reynolds:
“I have to go with (b.) You really don’t want to leave that decision in the hands of someone whose stock options rise in value if you die.”
I’ll take the greedy businessman over the political hack who will make his decisions on who lives and who dies on the basis of party and faction. I read your description of Medicare, largely right, above. It really undercuts your argument when you come to think of it, to wit, the biggest government health program already makes political decisions.
Comment by jackson1234 — 11/24/2009 @ 12:10 pm
Jackson:
Both private insurers and government make health care decisions. If you assume:
1) That both find an advantage in collecting as much money as possible while paying out as little as possible, and
2) Private insurers are more efficient, you are left with:
Conclusion: private insurers are more likely to kill grandma.
Of course in reality it goes more like this:
1) The CEO of Aetna makes more money every time he can refuse to pay.
2) The GS 16 gets diddly squat for cutting anyone off, therefore:
Conclusion: private insurers are more likely to kill grandma.
In fact, aside from your assumption of government perfidy, I doubt you can construct a logical argument that would lead to the opposite conclusion.
Comment by michael reynolds — 11/24/2009 @ 1:55 pm
Interesting, Michael, that you wrote private industry is more likely than government to kill grandma. I agree. And government is more likely to kill junior than grandma for the reasons I wrote previously. I believe you agreed there.
Anyone who thinks there will be any degree of altruism or even rationality from either private concerns (MooseR, Jackson1234) or the government (you, Marge) is deluded. Until I hear someone explain how the status quo will improve with a government takeover I’ll pass on that option. The actual problem is the uninsured and underinsured, and that should be the focus rather than blind trust the healthcare industry will become Santa or a federal-run, single-payer system will be any less of a political hack job fuck up than Medicare is.
Comment by obamathered — 11/24/2009 @ 4:54 pm
@jackson1234:
“I’ll take the greedy businessman over the political hack who will make his decisions on who lives and who dies on the basis of party and faction.”
Really? Good luck with that.
Slight disagreement though. The middle-level bureaucrat isn’t making paper-shuffling decisions based on party loyalty — they’re making decisions based on getting out of the office at 4:30. Health-Care “decisions” won’t be heard by Senators and Representatives . . . but by regular working stiffs.
Do you think that IRS paper-pushers do their job entirely differently when a new administration comes into power? Or the DEA? Or the EPA? The case worker doesn’t say to themselves “How can I promote my political ideals with this case?”, they say “How can I close this case?”
And assuming politics does come into play, the other party INSIDE the government can expose it. When politics in the Justice Department became SOP, the Dems screamed bloody murder. In a private company, who INSIDE the company is there to argue for the other side, the patients? Nobody. Unless the Insurance company is idiotic enough to write in documentation “lets kill off these dog policies that cost us money by keeping people alive”, then the patients (YOU) are SOL.
If a caseworker at a private insurance company can avoid paying a big medical bill for a patient, they can get a promotion, a bonus . . . financial incentive for themselves. If a case worker in the government can block a payment . . . they get squat.
Who has an incentive to screw you? Whether or not they actually DO act in a malicious manner . . . who has the incentive?
Comment by busboy33 — 11/24/2009 @ 5:51 pm
It looks like we’ve wandered back into the “doctors are foot-rustlers and tonsil-diggers” territory. The problem I have with the heart of your position is that it seriously distrusts doctors to act in the best interests of their patients in favor of their pocket book while we can trust politicians and bureaucrats to do the right thing. The argument of “we’re paying for it so we should have the ultimate say in it” paves the road to a massive erosion of personal liberties - particularly when liberals want to move us to a system where the government pays for everyone and for ‘every thing’. You’re comfortable attributing altruistic virtue in bureaucrats and politicians (if I’m not misreading you it seems because you think they accurately represent you) and I’m more comfortable attributing altruistic virtue to doctors. Also, I don’t see how getting Medicare to demand these sorts of meetings with doctors solves the problem in your mind - if these doctors are so sinister that they are going to give their patients bad medical advice then how does forcing them to give this bad advice fix anything?
Comment by Bald Ninja — 11/25/2009 @ 8:21 am
@BaldNinja:
I think MikeReynolds is more talking about what I mentioned in the post above — incentive.
Nobody is claiming all doctors are greedy and evil. Nobody is claiming that all politicians (hell, ANY of them) are selfless and altruistic.
The issue here specifically is incentive. Pay-for-service by definition incentivises service, not care. It creates a constant “push” for everything the medical providers do. Does that guide and control all their decisions? Of course not.
Does it have an impact? Surely it must.
No doubt most (if not all) doctors make decisions for the good of the patient. Maybe the doctor advocating radical and extreme treatment to prolong somebody’s life for a few weeks is doing so primarily because they don’t want their patient to die — that’s sort of a big part of their job.
But doctors are ALSO influenced by selfish concerns . . . demonstrably so. Ever seen a pharmaceutical rep? Ever wonder why they almost always look like hottie covergirl models? Its not because of their extensive knowledge of the product line. Do doctors prescribe the new (expensive) drug-of-the-week becasue GSK incentives them to do so? Some do. Lots do.
Lets say I’m a doctor. My patient is terminal. I don’t want them to die. Lets try a major procedure. Might not help . . . but doctors often see patients as things rather than people (occupational hazard), and trying different procedures and treatments often has a “why not”, “playing with a big new toy” flavor.
The fact that I can get paid more for two weeks of treatment than I did for the last two years of the patients treatment can’t realistically be considered a “non-issue”.
Does it drive treatment decisions? Probably not. Is it an inherently bad way to pay for care? Not necessarily so. But thinking its not a factor to consider when looking at the issue seems naive.
Comment by busboy33 — 11/25/2009 @ 3:13 pm
The ‘delicate’ issue we are faced with is this:
health care is too expensive to give to everyone.
There is no way we are going to get cost down without sacrificing care and provide it to the Baby Boomers.
We can make some people suffer a lot or we can all suffer a little.
Suffer a lot means that Charlie can’t get his kidney and liver at 68 years old.
Suffer a little means that 40 year olds don’t get mammograms and 20 year olds don’t get pap smears.
The question we have to ask is:
Does Charlie deserve a double transplant at the cost of a thousand mammograms (or ten thousand) that will save the life of two (or ten) women nearly have his age?
Guess what? Charlie says yes, and the two women say no. Charlie votes and only half of the two women do.
Guess who wins?
Here’s the good news. For those of you that have recognized the problem of incentives, you’ll appreciate this.
There is a way to incentivize Charlie to trade the kidney and liver for a dirt nap.
In doing so, the government saves thousands in costs, Charlie’s heirs get bequeathed enough to bury him (and then some), and the economy is rescued fromt he brink of collapse.
Details forcoming.
Comment by Steve — 12/5/2009 @ 1:42 pm