quote:Of the many billions of dollars spent on health care every year, a wildly disproportionate amount is spent during the final few tenths of a percent of a life, prolonging the inevitable, agonizing end for both patients and their families. It goes without saying that the billions of dollars spent on aggressive but futile end-of-life care would be more wisely directed toward education, food programs, medical outreach, and housing—all of which we know lead to longer, healthier, happier lives. .... So in a different spirit entirely, I propose an alternative—the "life incentive." I urge the government to spend money on helping us to live well. Offer everyone a one-time payment to spend in our prime years, asking in return that we waive our right to end-of-life aggressive medical treatment in favor of humane hospice care. Use the money to take your children to the World Series, start a small business, ride a horse through the Sierras, learn to play the piano, set your watch to Old Faithful. And along the way, resolve whatever uncertainties or disputes that might prevent your family from saying goodbye when the time comes.
I would be against a few months ago anyway, on principle, but after the experience with my step-brother, this sounds horrible to me.
Everyone said that there was very little chance. He was still alive, but just barely. He had been without oxygen. They didn't know why his heart gave out. He was having seizures, and everything the writer described in that article was done to my step-brother. After a week in a deep coma, he woke up. After three weeks in ICU, he was moved to a rehab. After two weeks there, he's home. They've put in a defibrillator, and he'll be fine. He's not running up and down stairs, but he's alive, he's still Ryan, and he can be a father to his two little boys. He has a long life ahead of him, and it is precisely because all the expensive procedures were available to him.
How do we know what is futile? Aggresive care where the patient still dies may seem like a waste, but we don't know who may be helped and who may not. The aggressive care on my step-brother seemed pretty futile, but it was needed, and it worked - it did everything we could hope for, and he's alive because of it. There's a reason we ask the nearest and dearest to make the decision of when to try or not - it's their loved ones whose lives he'd be tossing away in order to buy tickets to the World Series.
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This is leaving off mentioning the sheer impossibility of regulating who gets what care when we do not have a centralized health care system.
Posts: 26077 | Registered: Mar 2000
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My husband often spoke to me of the futility of CPR. Even when they can get a normal heart rhythm back and deliver someone to the hospital still living, few of those people ever lived to be discharged from the hospital. He would speak of the high cost of advanced life support rescue unit, the drugs, the training, all the effort that goes into something that very seldom works.
Then, he came home one day and said to me "I know now why I've run hundreds of codes on people. Because today it worked"
A patient they did CPR on and got to the hospital came by to see them to say thanks. CPR rarely works, but when it does it saves a life. So, who decides when it's worth trying and when it isn't?
And even in a case when it didn't "work" like my grandfather, who had CPR peformed and made it to the hospital alive but never came home - he died before being discharged, who is to say that even the prolonging of that life isn't worthwhile? Yes it may have been agonizing for the family - it was very hard for us, but there were also some wonderful moments during the last weeks of his life I wouldn't trade for anything. The time he reached for my daughter - not able to recognize that was his great-grandchild but still able to take joy in holding an infant and smiling at her. The time I sat in his hospital room by myself and held his hand and talked to him for an hour about my hopes, my dreams, and my prayers. The lessons I learned about love and devotion, and letting go. Had they not done CPR and not put him in ICU and just let him die on the floor in his home - I would have missed out on a lot of that.
My grandmother died suddenly. CPR didn't work - she collapsed, and died in route to the hospital.
Yes, it was tough to watch my grandfather lying in an ICU bed. But I cherish the weeks I had with him and the moments I had at that bedside. I much prefer it over the situation with my grandmother - losing her so suddenly there was no time at all to say goodbye to her.
We spend enormous amounts of resources on end of life care. In my view, it's absolutely worth every penny.
Posts: 14428 | Registered: Aug 2001
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How, and who, would determine that this was truly "end-of-life" and terminate end of life care?
We had our own EMS captain collapse on the scene of an emergency call. CPR and advanced life support on him all the way to the hospital. Turns out the electrical part of his hear was malfunctioning -- not a true heart attack, no blockage - -it just didn't know to send the signal to fire. After several days of intensive care, he was given an internal pacemaker that keeps him alive.
He's only 40 years old or so. If his heart had stopped and we did CPR or support, he wouldn't be here to support his family today.
The article says "futile end-of life care" -- how does anyone determine when it is futile?
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And even from a purely economical view, those aggressive life support measures don't hurt the economy any. Think of where the money goes. In the training and pay of the medical staff who performs them, and the manufacturing of the equipment used. You could argue that the equipment is often made overseas, but thats about it. Its not like the money dissapears or something. If everyone took their kids to see the world series instead, the money would just end up in someone elses pocket.
From an emotional/society view, his argument holds even less water.
Posts: 5656 | Registered: Oct 1999
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And how many people, if not saved -- would then not be around to economically support their families -- often times death creates a huge financial burden on a family, and I don't see that the economic savings would counter any possibility for a lot of new people on welfare or social security.
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In the US, "futile end of life care" equals an impoverished six-month-old African American boy in Texas, while "non-futile" equals a 41-year old white woman from Florida with substantial religious-based social support.
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Let's assume for a moment that such a scheme was possible. Isn't it true that you could save more lives per dollar used by educating the poor, giving them simple prophylactics, or just screening people for cancer yearly? I mean, saving someone from a heart attack is nice for his family, and all, but that doesn't mean it is the best possible use of those resources. Poor people have families too.
Posts: 10645 | Registered: Jul 2004
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KoM, it ISN'T possible, and even if it was it wouldn't be desirable.
I worked as a medic in the Army, and was NREMT certified. I know that CPR is better than nothing, but that it doesn't usually work...23% is the highest success figure I have seen, and most figures are lower than that IIRC...it HAS been a few years for me, after all.
The point is that the families are in charge of the care and treatment, and you can't start allowing people do die because you feel they are wasting their money.
This is a straw man of the highest category, because it assumes that all the options are mutually exclusive, when in fact they are complimentary.
I could not allow you to eat, and use the money saved from not feeding you or providing you care for your life to help 10 different people in Africa, just by buying food...
But would that be the right thing to do?
I could steal someones computer and sell it, and give the money to UNICEF, but that wouldn't make my actions moral.
I see his point in this article, but I find it to be erroneous, arrogant, and presumtious...not to mention immoral.
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If your loved one is dangling over a cliff and they will surely fall to their death if nothing is done, could you turn your back on them and walk away?
Could you do it if a stranger was dangling there, with their life in dire jeopardy?
The writer of the original piece seems to want us to, as a group, turn our backs.
Sure, many times the life is not prolonged for any period of times, most times the life is not saved but death is delayed for a short time. Now and then, once in a while, a life is truly saved.
While that may make it worth it, the real issue is that if we live lives where we don't try and no one will try for us, what is the use of living a life at all?
Posts: 2848 | Registered: Feb 2003
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Hypothetical case: A 46 year old man with a progressive neuromuscular disease that has left him unable to move, talk or breathe independently. Is this someone for whom treatment and expensive care is futile?
OK, so the case isn't all that hypothetical. It is my husband who has advanced Fascioscapulohumeral Muscular Dystrophy. He can not move even a finger, but he has some small head movements. He can not speak above a very hard-to-discern whisper. He can not breathe without a mechanical ventilator.
So, what about quality of life? Well, he lives at home with his family, and is a good husband to his wife (me) and a good father to our son. He works a full-time job in a major telecommunications company doing computer science research and development. He is active in our community, goes regularly to religious services and hosts a religious study group in our home twice a week. For fun, after work, he likes to catch a ball game, read Tom Clancy novels, and solve the New York Times Sunday Crossword Puzzle (not in pencil, not in ink, but MENTALLY). He holds a Masters Degree in Computer Science and a PhD in Mathematics.
All this would be impossible without some pretty expensive intervention. There are private-duty nurses who attend him while I am at work. There is the cost of medication, doctors and equipment.
But what is the would be the cost to society if we were to discard such wonderful people as my husband? I believe that our humanity is, in part, defined by how we care for our most vulnerable.
Bless the ICU and all the wonderful healers who saved my husband when he needed them!
Posts: 10397 | Registered: Jun 2005
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Kwea, of course you're right; I did not make it clear enough that I was speaking only to the spure logic of the argument, not the morality.
Posts: 10645 | Registered: Jul 2004
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We do deny expensive end of life care to plenty of the people here. Everyone without insurance goes to the free hospital and gets that kind of third-world care. A man I know of who needed dialysis to live, for instance, but had no insurance, was sent home to die within a week or so. He wasn't a particularly good long term prospect as he had HIV and no money for the drugs to keep it in check. These kinds of decisions happen all the time involving people without insurance. Life has a lot of luck involved.
My dad's hospital bill was over $300k, but he had good insurance that covered almost all of it. 1) He might have recovered and gone on to live 10 or 20 more years. 2) It's not like it wasn't his money. He and his company paid health insurance premiums for all his working life and during his retirement too. Had he invested all that money instead, it would have earned more than enough to cover it. That's how insurance companies do it. They don't lose money.
People are allowed to make living wills to cut short their own end of life care if they so choose. That's all we need. People should be allowed to decide for their own lives and their own money, not for the lives and the money of others.
Those who say "we should take all the money spent for this and spend it for that instead" are being silly. It doesn't work that way.
Posts: 6246 | Registered: Aug 2004
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I'm very glad Katie's brother recovered, and that Tante's husband is getting good medical care.
However...
Just to play "bean counter"'s advocate for a minute here, the Slate author has a good point, although he fritters it away in the last paragraph.
quote:Of the many billions of dollars spent on health care every year, a wildly disproportionate amount is spent during the final few tenths of a percent of a life, prolonging the inevitable, agonizing end for both patients and their families. It goes without saying that the billions of dollars spent on aggressive but futile end-of-life care would be more wisely directed toward education, food programs, medical outreach, and housing—all of which we know lead to longer, healthier, happier lives.
From a strictly utilitarian POV, this is hard to argue against. Redirecting those resources to address other medical and health-related problems would make more people healthier and happier.
Simply put, it is far more difficult and expensive to keep very sick/old people alive than to keep people of average health healthy. It's just the nature of medicine and medical research.
And, if trends in medicine continue, every industrialized country will have to decide these priorities in a more strictly either/or fashion in the 21st century.
HOWEVER, few people volunteer to be sacrificed medically for the good of the rest of society. I know I don't. I'm reminded of the scene in Monty Python's The Meaning of Life, where the guys knock on a sap's door and demand his liver, because he had signed an organ donor card.
So, unless people have signed DNR (do not recussitate) orders or their family refuses drastic treatment for them, they get treated.
But if trends continue, even more money will be spent in patients' last months and days of treatment. Eventually, it will reach a point where insane amounts of money are spent in the last week of life (if it hasn't gotten there already.) This money is health care dollars that won't be spent elsewhere, so Xavier's point is very limited--this does constrain the overall health care budget of a country.
Where is the line to be drawn? If 40% (for example) of the average patient's health care dollars over a lifetime is spent in their last month of life, doesn't this decrease overall health and life expectancy, and increase mortality rates? If not 40%, then where? 70%? 90%? At some point, it won't make sense as a society to keep people alive no matter the cost.
Posts: 6316 | Registered: Jun 2003
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I think people should consider putting less into ICU, but it has to be the choices of the families involved and not policy. There can even be public policy to educate people about the proportion of money spent vs. the rates of recovery. But the flow of money into the health care system will dry up real fast if the public gets this general picture that some bureaucrat with a balance sheet is in charge of who is worth saving. The decisions can be influenced by compassionate physicians.
Posts: 2010 | Registered: Apr 2003
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quote:Originally posted by Morbo: I'm very glad Katie's brother recovered, and that Tante's husband is getting good medical care.
However...
OK, my husband has been on a ventilator for over five years, working full time and being a productive and contributing member of society the whole time. Without medical intevention, it would have, of course, been the "last month" of his life, or more likely, the last few days. I don't know that you can draw a direct line from the expense of the care that he receives to the withholding of care from someone else. The healthcare puzzle is too complex for that. Is the expense worth it? To save and maintain the life of a man with such a rich quality of life, a good man, a veritable tzaddik , what expense is not justified? And can you explain how his life is harming anyone elses life?
I am not impartial on this subject, when it comes to my family, I am as biased as anyone else, but I can't stand the "However" in your argument.
Posts: 10397 | Registered: Jun 2005
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posted
Also, I can see both sides of the coin. I am a hospice nurse, and I understand that there comes a point when further curative treatment is futile. Death is not in itself tragic, unless it comes before the person has been able to accomplish their life's work.
It is presumptuous and wrong for those on the sidelines to second-guess whether hospice, end-of-life, palliative, or curative, life-sustaining therapy is appropriate. The decision belongs to the patient, the caregivers and the medical professionals whom (we hope) understand what they are doing.
Posts: 10397 | Registered: Jun 2005
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