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Re: End of life health care
Old 01-25-2007, 08:26 PM   #21
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Re: End of life health care

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Originally Posted by Brat
The issue with futile treatment is 'who pays for it'. Our culture has difficulty making choices when it comes to health care. Before health insurance was common the family paid the hospital and physician directly. Few families opted for futile care. Since that time health care has become more expensive and we have insurance. No need to make a decision to stop futile treatment when the family isn't paying for it and the patient isn't able to say stop.

The question is how do we build into our health care system incentive to stop futile treatment.
No, I disagree with you, Brat. Financial considerations in this setting rarely if ever drive the decision in my pretty extensive experience in such matters. It's more a matter of families being more empowered, doctors less so; medicolegal climate is edgy, inappropriate hopes for a miracle, and the other factors I mentioned above.

You know by now that I am no defender of the system, and finances drive a lot of bad decisions, but in this case when the gloves are off I have never seen this enter the picture. (In fact, what I get paid to maintain a critically ill, dying patient compared to the time I spend with patient and especially family, probably would be a disincentive, if I ever thought about it). Not everything is about the money; let's not get cynical .
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Re: End of life health care
Old 01-25-2007, 10:00 PM   #22
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Re: End of life health care

My father died of pancreatic cancer 10 years ago. At the time he had excellent health care coverage, and we felt that because of that they would have given him chemo up to the day he died. However, he knew it was terminal and did not want his life to be prolonged for an extra few months with a poor quality of life. The treating Dr was not happy, wanted my father to continue treatment, we felt he almost saw my father as a experiment.

My IL's on the other hand are now mid-80s and the amount of money that is going to be spent on their healthcare before they die is staggering. They seem to be on a never ending round of Drs appts. for aches and pains, looking desparately for something that is going to prolong their lives even though their quality of life is poor.

The other issue I have problems with is the money that is spent on keeping premie babies alive, who given normal circumstances would die. Instead Drs make heroic efforts, spend endless amounts of money to give a child with significant health issues back to the parents to cope with.

The weirdest thing for me is people will argue against euthansia because it's against God's will but advocate extensive medical treatment for premature babies that would otherwise die.
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Re: End of life health care
Old 01-25-2007, 10:02 PM   #23
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Re: End of life health care

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Originally Posted by Old Army Guy
ditto, for sure. A DNR should be honored -- I am sure there are exceptions but it should stand.
Took Gpa to ER for a fall (this was a couple years ago) and he had a DNR on file. While I was waiting with him in the ER (he was hooked up to heart monitor) he coded. Nurses came rushing into room, pushed me out and proceeded to revive him. Is this standard practice to revive even with a DNR?
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Re: End of life health care
Old 01-25-2007, 10:09 PM   #24
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Re: End of life health care

DangerMouse, we agree.

Rich, I honor your efforts but I still think that our culture has a problem with futile treatments. The FL Governor performance is a prime example.

This is the reason why so many are hesitant about the cost of health care. Oregon tried to set priorities based on outcomes, but the Feds said no. So, what is the solution
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Re: End of life health care
Old 01-25-2007, 10:17 PM   #25
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Re: End of life health care

My wife says DNR's are routinely ignored at her hospital...sometimes unintentionally (patient is crashing, lets do something...good...they're alive again...what does the DNR say?) and sometimes the doctor or nurse does it because they want to and feel its the right thing from their perspective.

Good luck...
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Re: End of life health care
Old 01-25-2007, 10:24 PM   #26
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Re: End of life health care

The only solution is to stay out of the hospital!

If you go to the hospital the staff believes that you are there for their best efforts to send you out alive. If palliative care is appropriate use hospice and absolutely tell your family that you are not to leave your abode. Maybe tell them that your will/trust provides for their dis-inheritance it your wishes are not respected.

That doesn't do much for mom's who deliver prematurely.
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Re: End of life health care
Old 01-25-2007, 10:33 PM   #27
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Re: End of life health care

Quote:
Originally Posted by Cute Fuzzy Bunny
My wife says DNR's are routinely ignored at her hospital...sometimes unintentionally (patient is crashing, lets do something...good...they're alive again...what does the DNR say?) and sometimes the doctor or nurse does it because they want to and feel its the right thing from their perspective.

Good luck...
I feel that at some level there is a total denial of reality.

If we can just keep Granny breathing for another week, we have accomplished something wonderful; even if Granny is a a total vegetable.
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Re: End of life health care
Old 01-25-2007, 10:52 PM   #28
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Re: End of life health care

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Originally Posted by Brat

Rich, I honor your efforts but I still think that our culture has a problem with futile treatments. The FL Governor performance is a prime example.
Appreciated and I fully agree. I just don't think that this particular issue is money-driven, for once.

My gut reaction is that it reflects malpractice fears, perhaps understaffing and insufficient time to know the patient's desires til it's too late, some cultural bias, and a defensive posture when there is any ambiguity whatsoever. Families can complicate things despite individually good intentions.

That said, when the patient's wishes are clear and made in a lucid time, that is what is right. Trying to do that in the face of a tearful, distraught spouse/POA who is begging you not to is a moral dilemma that few outside the profession can appreciate. This doctor does not think he is God.

Best defense: get all your ducks in a row: family (all of them), patient, surrogates and medical team in advance; make it explicit at the moment of admission (not when a code is called) and gently but unequivocally insist that the attending physician (not one of the consulting physicians) write the order to that effect. Might not be a bad idea to clarify that even if the impending cause of death is unrelated to the disease of concern, the wishes should be honored. That should work. Leave any hint of ambivalence or family disagreement on the issue and the outcome is anyone's guess.
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Re: End of life health care
Old 01-25-2007, 11:08 PM   #29
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Re: End of life health care

When my mother was losing her struggle with colon cancer, she and my father chose hospice care for the last several weeks of her life. She eventually went into a coma and died a few days later at home. We all knew the decision was the correct one, but it didn't make it any easier to experience. I think my younger brother would have wanted to try any heroics available. He had more trouble dealing with her death than the rest of us. He suffered. If she had been in a hospital where other treatments were available, he would have tried hard to explore those treatments. It would have been difficult to resist him since he was suffering too, and you can't really aleviate that kind of suffering by trying to reason with him.
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Re: End of life health care
Old 01-25-2007, 11:28 PM   #30
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Re: End of life health care

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Originally Posted by Rich_in_Tampa
That said, when the patient's wishes are clear and made in a lucid time, that is what is right. Trying to do that in the face of a tearful, distraught spouse/POA who is begging you not to is a moral dilemma that few outside the profession can appreciate. This doctor does not think he is God.
Rich, that is so true. Luckily for us, my Dad was in and out of a hospice for respite care, and while he was still in fairly good condition, they went over what his wishes were. He was quite clear that he was DNR. However, when it came to the crunch, if my mother had of been there at the time he passed, you could guarantee she would have been calling for the crash cart. The stupid thing is it wouldn't have been about keeping him alive because he wanted to be, it would have been because she was only thinking of her needs and wants. Rational was not a word that could be used for my mother at that time (or any other for that matter).
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Re: End of life health care
Old 01-26-2007, 08:50 PM   #31
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Re: End of life health care

Your discussion making a rational decision about something people are unrational about.

If someones in the Er they havent likely reviewed the DNR or paperwork in the life directives. They are going to work on you . They might stop sooner but they arent going to say. I think this guy might be a dnr.
If your in the room and you code the nurse they will have a copy of the dnr in the chart and we make everyone do an advance life directive.
Ok so now your in the hospital and your bp drops. You dont quite code . They are going to move you to icu. You cant eat . They will likely put you on nutrition via an iv. They may run many tests. Put you on very expensive antibiotics. etc etc. Its not too dificult to run up and big bill before you reach the code blue stage.


Personally I thought that minorities and low wage earners was what skewed our life expectancies. Babies dying and the such ?
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Re: End of life health care
Old 01-27-2007, 08:49 AM   #32
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Re: End of life health care

Rich,I'm sorry to disagree with you but I do think some of it is about money .The difference in treatment of non-paying patients and ones with good health insurance is staggering .I've seen it time and again in my 39 years of nursing .Also isn't it true that two physicians have to agree the patient is terminal in order to apply the DNR.
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Re: End of life health care
Old 01-28-2007, 11:36 AM   #33
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Re: End of life health care

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Originally Posted by Moemg
Rich,I'm sorry to disagree with you but I do think some of it is about money .The difference in treatment of non-paying patients and ones with good health insurance is staggering .I've seen it time and again in my 39 years of nursing .Also isn't it true that two physicians have to agree the patient is terminal in order to apply the DNR.
In my state and hospital, you only need 2 physicians to withdraw life support that has already begun, in the absence of a relevent advanced directive, and with consent of the family.


Re: payor source, yes there is a big difference in reimbursement amounts. I am salaried and generally am not even aware of my patients' insurance status. Yet in either case, I have yet to see that play out in terms of applying DNR. Not to sound cynical or insensitive, but in theory you could imagine an extreme where it might be financially advantageous to apply DNR to nonpaying patients to lower your uncompensated work load.

But in the real world that I see, no, DNR and money don't connect. Maybe it's different elsewhere, but not in the 3 states I have practiced in.
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Re: End of life health care
Old 01-31-2007, 01:55 PM   #34
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Re: End of life health care

Ok, I am going to pour gas on this fire, again....

Good old Newt ( :P) has an article about how to improve the health care system, "Value-based health care means that providers, health plans and other health care professionals are rewarded--and procedures and products are encouraged and utilized--based upon the true value they bring to the consumer. This means critiquing every aspect of the delivery of care, divining its true value by knowing its cost and quality. This formula works in every other market, and it must be the foundation of health care."

How do you get the consumer of health care to make the hard choices on end of life care if there isn't a substantial co-pay in play?

Maybe hospice care should be offered for minimal cost to the patient, hospital services higher cost.

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Re: End of life health care
Old 01-31-2007, 02:24 PM   #35
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Re: End of life health care

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Originally Posted by Brat
Ok, I am going to pour gas on this fire, again....

Good old Newt ( :P) has an article about how to improve the health care system, "Value-based health care means that providers, health plans and other health care professionals are rewarded--and procedures and products are encouraged and utilized--based upon the true value they bring to the consumer.
I think good ol' Newt should test his value-based principles on his parents & kids (and his girlfriends) and let us know how that's working for him...
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