End of life health care

[lets-retire]

All of the recent talk about health care has raised a few questions in my mind. I'm not attempting to bait anybody into a fight, I'm just curious. I've heard it repeated several times on this forum that a large percentage of our health care spending is from heroic end of life treatments. I'll assume this is true because it came form some knowledgeable people, IIRC. It is also pointed out that our life expectancy is sorter than many other westernized nations.

This is where my question comes in. If we cut our heroic end of life treatments to the level provided in other countries wouldn't our health care cost come down to more closely reflect the amount spent on health care in other countries? The other side is wouldn't our life expectancy also come down even lower than what it currently is? my last point is would that seem to indicate there are other issues than the access to health care as causing our shorter life span?

 

[Rich_by_the_Bay]

Lets, your question and comments cover several areas. While I am too tied up to pull the references for your right now, I believe that a disproportionate amount of money is spent in the final 6 months of life (often over age 80) including ICU level care which is unthinkably expensive.

The contribution of this care to life expectancy is small, measured in months at best. If I can find the reference I'll post it here. Quality of these few months is typically low.

As far as cost comparison to other countries, we are very high in cost (e.g. 30% more) in virtually all levels and life stages of care, not only end of life.

Our life expectancy mediocrity is more related to lifestyle issues than to our health care as I recall. Obesity, tobacco, sedentary habits, helmets and such.

Even in medically preventable deaths such as premature births, we are low not because the care is inferior, but rather because of lack of access to that care (including unwareness, cost, cultural impediments, immigration status with fear of disclosure to the system, etc.).

Complicated. I see it as diminishing returns - less and less gain for increasing costs once a certain threshold is reached. Social, legal, adminstrative, and financial incentives all play a role.

Hope this helps.

P.S. This morning I took care of an 83 year old man with uncurable lung cancer who recently was diagnosed with new colon cancer. He has a single metastasis to the liver; removing that has some limited benefit for many patients, extending life for months. His life expectancy before surgery was probably 3-6 months. They operated. He is now in the ICU fighting for his live, on a ventilator, dozens of expensive meds, probably neurologically compromised. He will end his life in the hospital or maybe with hospice care for a few weeks before he dies. I'd guess his stay will cost well into the 6 figure range. The family insisted on all of this.

 

[lets-retire]

Thanks I was hoping you'd answer.

 

[Brat]

I absolutely agree.

The aged seniors I know do not want heroic efforts at the end of life. It is the family that insists and there are dynamics within the family that cause this result. Often it is the 'absent' child who rushes in to 'save dear old Dad/Mom', insisting on agressive treatment. I recall one person who wanted to maintain a parent until an out of town relative arrived, after all it didn't cost them anything (covered by insurance). That person had the health care power of attorney.

So, how do we fix this?

 

[Rich_by_the_Bay]

The aged seniors I know do not want heroic efforts at the end of life. It is the family that insists and there are dynamics within the family that cause this result. Often it is the 'absent' child who rushes in to 'save dear old Dad/Mom', insisting on agressive treatment. I recall one person who wanted to maintain a parent until an out of town relative arrived, after all it didn't cost them anything (covered by insurance). That person had the health care power of attorney.

So, how do we fix this?

BTW, that relative who whisks in at the final hour to delay withdrawal of care is often the one who feels guilty about not having been there for his or her parents for the past 30 years. It is very hurtful for everyone, and very difficult for the doctors to know what to do.

As to fixing it, I have no clue. I think that education, open discussion early, advanced directives are all helpful. I see no way that the doctor can or should discontinue care if the family wants it to continue. This occurs regularly and I guess you get a knack for handling it, but it's not something that we as a culture handle very gracefully.

 

[Brat]

I agree that this is a cultural issue. A friend of mine could not get a hospital physician to terminate aggressive care when her elderly father had a devastating stroke. The father's primary care physician was on vacation. Only on that physician's return was the health care directive honored. Families under the stress of a parent's passing aren't up to fighting with a hospital.

Maybe we should change Medicare so that it requires the signature of the family for aggressive end of life medical treatment. They should make a significant prepayment and get the bill for care as individuals. After all, if cost is no object they should put their assets where their values are.

 

[lets-retire]

I hate to say it, but it seems to me the only way to handle end of life care such as those brought up would be to have a checklist type control. If this procedure will result in extending the patient's life by less than say a year, then it cannot be paid for by general health insurance. I don't like that type of control, but if the family and/or patient are unwilling to know when to say when, then maybe it is time for an uncaring third party to step in and say stop.

Several months after my wife had a brain tumor removed, the doctor said he thought he saw a shadow on the MRI. She said it didn't really matter because she refused to go through the pain of having another one removed. It took me several more months to convince her that there might be other treatment options if there was another growth. She made me promise not to bring up another surgery, before she'd have another MRI done. She also told her mother and father that she wasn't going through another surgery under any circumstances. It turned out to be nothing more than a shadow and had disappeared on the next MRI.

 

[Rich_by_the_Bay]

I agree that this is a cultural issue. A friend of mine could not get a hospital physician to terminate aggressive care when her elderly father had a devastating stroke. The father's primary care physician was on vacation. Only on that physician's return was the health care directive honored. Families under the stress of a parent's passing aren't up to fighting with a hospital.

Well, yes, though that situation may have other agendas - if care is discontinued and the patient dies, should questions arise afterwards about the rightfulness of the death the medicolegal consequences for the physician may be severe. He/she may have felt that the risk of continuing the care (antagonizing the POA) were lower than the risk of waiting until the familiar physician returned. Ironically, the MD could get sued for NOT following the directives of the POA. At best it's a tough place to be.

 

[Khan]

A woman down the street died this past summer. She was 85 and was being driven to her regular chemo session (lung cancer after 70 or so years of smoking).

I just don't get it.

 

[Brat]

I know a fellow of the same aprox age, same disease and habit, who survived treatment about two years ago and is alive today.

Were I 85 and offered chemo I think I would pass.

 

[cute fuzzy bunny]

My wife comes home with these stories all the time. They're not always old folks with incurable diseases. One case involved a young kid that tried to hang himself and screwed it up, cutting off his oxygen and leaving him brain dead. Parents wouldnt consent to having him removed from life support for three weeks. Pretty expensive stuff.

A big part of the problem is that, aside from pain and suffering from the procedures, for many people its "free" to try to continue life as long as possible, even when the 'benefits' are pretty limited or non-existent.

I think that insurance and other 'free care options' should come with specific limiters. If a panel of doctors says its not going to do you much or any good, you should be able to continue care and have procedures if you pay for them yourself. If you show up from a car accident and werent using a seatbelt, you pay for your own care. You show up from a motorcycle accident with your head bashed in because you didnt wear a helmet, get out your checkbook. Get hauled into the emergency room with a heart attack because you're 100lbs overweight...pay up.

I'm betting some of these "lifestyle choices" and "elective procedures" get cut way back when your bank account is at risk. A little more personal responsibility seems to be in order.

 

[Brat]

The delicate balance here is to assure that the care provider gets paid. Many of our hospitals are walking financial tightropes.

I say if the committee says no more then the family posts a bond. And that committee needs to be available 24/7.

 

[FinanceDude]

Well...........I have a personal experience to share. My sister died last year of mesthatized breast cancer after a 6 and a half year fight. However, she was only 46 at the time. Would I have felt differently if she was 66 or 76 or 86? I don't know.........families make decisions based on emotion over logic when a loved one is involved.

My sister was smart enough to do some health directive planning. She made it very clear that she DID NOT want to be revived or placed on a ventilator when it got tough. The nurses and doctors told me that the day I got to the hospital. They also told me I had the option to overrule that if I wanted

I told them that my sister's wishes were my wishes. had I put her on a ventilator, she would have stayed alive another 2-3 days, according to the doc. However, she was hypoxic (comatose from lack of oxgen to the brain as her organs were shutting down), so at the end any "time" I would have had with her, she would not have known I was there anyways...........

Thankfully, her insurance was excellent, and paid just about everything. The total bill for her last 9 days was $85,000...........not huge, but significant.

 

[OAG]

I went through this several years ago. My Mother was 80 years of age, a smoker from teens to about 6 months prior to her death. She had a DNR which I attempted to give to the Doctor who ignored me for a while -- My Daughter who is an RN had to just about threaten the Doctor and the Hospital with a law suit if they did not honor the DNR. She was subjected to an extreme amount of tests, experimental procedures and much of it was painful. She begged to be left alone and allowed to "rest". She was finally moved from the hospital to a nursing facility to live out her remaining days as she was on about 100% Oxygen and could not return home. On the day of her death (after about 30 days in the Nursing facility) the Doctor still had her moved back to the Hospital via the emergency room. After about an hour in the ER the Doctor finally agreed she was dying and beyond medical help and had her sedated and moved back to the Nursing facility -- She was heavily sedated in the ER and the Nursing home and passed away that afternoon. The cost of her last day on Earth approached $10,000 which, I guess was cheap by most standards, but totally unnecessary from medical respects and especially from the patients respect. I am still pretty bitter about the entire episode and really think that if it was not for the fact that she has very good medical insurance a lot of this IMO unnecessary things would not have happened. She knew, and we all knew she was dying and just wanted comfort in her last days.

 

[donheff]

My sister was smart enough to do some health directive planning. She made it very clear that she DID NOT want to be revived or placed on a ventilator when it got tough. The nurses and doctors told me that the day I got to the hospital. They also told me I had the option to overrule that if I wanted

Does anyone know if this is true? (Not that they said it, but that family has such a right). I would find a way to come back from the dead and strangle the SOB who overruled my directive And, even though I would normally be loath to sue, I would sue the doctor who ignored my family member's directive unless he or she could show me some damn convincing justification.

 

[OAG]

ditto, for sure. A DNR should be honored -- I am sure there are exceptions but it should stand.

 

[Brat]

I count physicians among my good friends, I don't think they would not honor a DNR.

However, I do think that if one is presented and not honored a copy should be sent to the patients health care insurer. Let the hospital and physician fight with the folks who hold the money!!!

 

[Rich_by_the_Bay]

Does anyone know if this is true? (Not that they said it, but that family has such a right). I would find a way to come back from the dead and strangle the SOB who overruled my directive And, even though I would normally be loath to sue, I would sue the doctor who ignored my family member's directive unless he or she could show me some damn convincing justification.

I hear the frustration here, but there are circumstances which arise regularly that make it unclear what to do. Sometimes it's not black and white.

Example: patient has advanced directives, no ventilator or defibrillation as there is little hope for a meaning full recovery, etc. Now the patient comes in and goes in to respiratory failure not due to the underlying disease; say it was from aspiration or a collapsed lung, or a treatable pneumonia. The patient's underlying cancer, while advanced, had been stable. Unforeseen turn of events. Do we let her die even though there may be 3-6 decent quality months ahead? Now a family member steps up and says, override - keep her going, that's not what she was talking about in her advanced directives.

As a physician do you err on the side of letting her die (following her now questionable wishes), or do you keep her alive as the surrogate requests? Few would err on the side of letting her die if things were even the slightest bit ambiguous -- that's a one-way decision.

Example: patient has advanced directives, let me go, no heroics. As he nears death, a family member with health care POA has a change of heart -- it happens all the time. He says, save him, ventilator, defibrillate, etc. Despite sensitive and supportive counselling, he is adamant. All agree it is futile and the patient's wishes were clear. To let the patient go is effectively to "kill" them over the wishes of their surrogate. What would you do?

I don't doubt that some doctors simply disregard the wishes of family and patient, and I don't support that. But understand that in the real world, there are issues that make it not so easy. And that's not even considering the vague medicolegal issues, veiled threats by disagreeing family members, religious issues, etc.

Hope that helps explain why such situations can vex even the sensitive and well-intended family and docs. It's a hard job for everyone.

 

[donheff]

Thanks Rich. I can understand the dilemma. I am not too worried about myself because I have made my wishes very clear and DW and the family are sympathetic. But it is questions like the "possible 3-4 months" that make me worry. Everyone says I can use a fairly standard document to make my wishes clear but it is questions like those you pose that make me think maybe it makes more sense to list some examples and state what you would want done. I would list both of yours and state "do not resuscitate." The only reason I even want a POA is to make sure someone else doesn't keep me going unnecessarily. I would like my designated POA constrained to NOT stretch things out on a hope and a prayer.

 

[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.

 

[Rich_by_the_Bay]

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 .

 

[DangerMouse]

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.

 

[larry]

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?

 

[Brat]

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

 

[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...