60 Minutes aired a good piece about our health care system tonight [text, video] confronting the issue of how much money we spend on medical treatments for people who are at the very end of their lives, and how we deal with the very difficult decisions we’re faced with at the end of our lives or the lives of our loved ones.
The numbers are pretty extreme.
Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients’ lives.
But the issue really isn’t the specifics of the spending, or the sure-to-follow frothing about rationed care and socialism (don’t miss the comment thread on CBS’ site). It’s about our fear of death, and our very American desire to find some kind of a loophole. We always think we’re going to win the lottery. A patient in the story has multiple organ failure and is not a candidate for transplants, but when asked if he should be resuscitated if his heart should fail, even if it meant a prolonged and painful death in the ICU, he answers without hesitating – “Yes.”
We should do all we can when appropriate and when that’s the patient’s wish, but it should be informed and rational, not automatic.
The reporter asks the doctor at the center of the story if talking about refusing to pay for extreme measures for terminal patients is “a version then of pulling Grandma off the machine”.
The doctor won’t have it:
“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.”
Agreed.
It’s probably politically impossible right now, but it sure would be nice if we could collectively come to terms with the most basic fact of life: it ends.
Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients’ lives.
Wouldn’t this include a lot of people who died from the very medical treatment they are being billed for? Say for example a cancer treatment that only has a 50/50 success rate. For the half that lived the cost saved their life, for the half that died it was during the last two months.
Everyone who is diagnosed with a terminal illness and is within a month of dying should be given Ayahuasca and visit with a Shaman. In 5 quick hours they would be over their fear of death and would welcome the end of their own personal journey in a natural and dignified way.
Hell, for a infinitesimal fraction of $50b they could setup huge ‘end of life acceptance’ centers and have ceremonies running 24 hours a day.
Spot on Anthony. I watched this a bit ago. The stunning part was the lady who wanted “no extreme lifesaving measures.” She got a colonoscopy, a pap smear and was vistited by 25 specialists before she died. All of them billed medicare for their services.
Why the fuck does a woman in her 80’s need a pap smear?
The quoted doctor is using outrage to avoid the question. He actual answer would appear to be “yes, I do believe we should pull the plug on grandma, because we have better uses for those resources.” If that’s what he believes, he needs to give that answer and be prepared to defend it.
If we didn’t insist on socializing medicide, we wouldn’t have to “collectively come to terms” with any of this. Have a lot of money and want to spend every last dime of it buying every possible extra breath? Fine, it’s your money. Your kids don’t just get to decide that it would be better spent on them, and society at large certainly shouldn’t. Only to the extend that we spend collective monies on health care do we need to have collective health care priorities.
It’s religion – that thing that is supposed to comfort people at their time of death – keeping this sick, keep-em-alive-at-all-costs thing going. And don’t they teach that when you die is when you get your reward? Odd, then, that they’d want to delay heaven, no?
I loved the PAP smear for the 85-year-old lady with organ failure and metastasizing cancer. Used to see stuff like that a lot in health care when I was in that industry. Cardiac bypass surgery on people in their late 80s and nineties is pretty common.
As the son of a hospice nurse, Americans are afraid of dealing with death. They expect miracles to happen. Shit when you’re past the age of 70 and diagnosed with cancer, just accept the fact your cancer is a slow growing one and don’t do chemo. Chemo after the age of 70 isn’t good and will wear your body out faster than not doing chemo and lead to a quick death. That’s geriatric hospice. I’ve seen the unspoken side of pediatric hospice. That’s something the media doesn’t show.
@4
I think what the doctor was saying is that the medical industry is creating resources that are not needed. Profit is the motive not health care. Rather than having a rational discussion about end of life health, they are more concerned with billing insurance/medicare for as much as possible while they can. Someone is going to have to pay for that third MRI machine.
@4
I think what the doctor was saying is that the medical industry is creating resources that are not needed. Profit is the motive not health care. Rather than having a rational discussion about end of life health, they are more concerned with billing insurance/medicare for as much as possible while they can. Someone is going to have to pay for that third MRI machine.
goddamn stupid posting system. I blame that eastside chick with the sunglasses in the pioneer square joint cover ad on the right.
@6-my grandmother was just diagnosed with a very treatable cancer and she is past the age of 70. i don’t want to see anyone suffer through chemo, but for her to just turn away and quit would be tragic. not every elderly person is the same.
The phenomenon of “keep-me-alive-as-long-as-possible-whatever-the-cost” is a direct outgrowth of having someone else (insurance, government) pay for healthcare. Shift the financial incentives and patients’ (and their families’) attitudes will change in a hurry.
11
And that is the critical flaw in the Democrats/Obama’s health care “plans”- they do not confront that difficult (and politically toxic) dynamic and instead promise more of everything to everybody (except the “rich”) at less cost.
Can’t be done.
What will happen, once “can’t say no to any voter or special interest” government gets a bigger hand in the system is that costs will SKYROCKET.
Not dealing with death is a huge problem indeed. Doctors can treat us for pain but not suffering.
I will say though. . . the doctor on the program seemed to want guidelines and regulations to take his conscience and ethics out of end of life issues.
He wanted to be able to tell patients that they wouldn’t treat for [x] because “the rules says so.”
Sorry doc. . . but I don’t think you should try and regulate culture. . . and guess what? if you wanna’ be a doctor YOU’RE gonna’ have to get used to people dying as much as they do.
@11
Fuck you.
When my wife was dying (at the ripe old age of 40) she got to think about her little one and family. . . she didn’t have to think about the cost of her treatment – what a fucking horrible shame, huh?
Speak for yourselves.
I plan on living forever.
There are many issues Americans treat with emotion rather than hard, cold reality. We seem to think that anything can be solved with buckets of money. It can’t. It’s a corruption of thinking.
wouldn’t death panels actually reduce these costs? that was a great idea, sarah palin!
@15
“her little one”.
Ironic.
That’s who is going to pay for all the health care the government is borrowing money for (43 cents of EVERY dollar it spends…).
@19 Who is paying for it now?
One of the most vivid examples of everything wrong with the American Way of Death is the study that came out a few months ago that people who went to Hospice actually lived longer than those who went for the heroic measures.
@11 & 12,
Good idea. Let’s just make everyone pay for their own healthcare directly. That way we can go back to the good old days before insurance. That was fun! Rich people got all the care they could possibly want and more. The wealthy loved the system. The poor, middle class and everyone without the last name Rockefeller or Carnegie didn’t get to see the Dr because they had to choose between seeing a Dr and feeding their children. Most people never saw a Dr and died young. Boy I sure do miss that system.
@4,
I notice that you point out the joys of the same system. You’re right. Rich people can spend all their money and get top of the line treatment. I see that you stopped short of the logical conclusion to that statement which is “fuck the poor!”. They’re poor so they just don’t get health care. Really though, who cares right? They’re poor. Of course under your plan it’s also “fuck the middle class” and “fuck anyone who can’t pull $100,000 out of their ass at a moments notice for emergency treatment”.
Thank you for that last line. I’m in a constant, relatively friendly, argument with my co-worker who decries any mention of cost/benefit analysis for medical care. I’m not sure we can overcome this point since I tend to feel mine is based in the straight forward reality that death happens to all of us, and we need to discuss that as adults without immediate rejection or cries of unplugging grandma.
FWIW on the anecdotal level, I’ve watched three of my grandparents pass away (two grandmothers and a grandfather) after my parents signed the orders to not revive or continue treatment. It’s gut-wrenching, it’s hard, and there is grief but there has never been regret. I’m not sure having them kept alive for three more months would change any of that.
If adding ten minute to life costs a billion dollars, not worth it.
If adding ten minutes costs two cents, worth it.
Everything in between needs to be measured and discussed.
Because pretty much 99% of what we got today IS collectivzed cost sharing some of it called “insurance” and some of it called “government health plans”
of course the biggest socialized feature of our health system is the medical bankruptcies, a system in which medical debt is charged to credit cards, followed by bankruptcy, effectively and efficiently burying the true cost from our vision as all lenders raise rates to cover the risks of bankruptcy.
Also socialized: medicare, medicaid, state l and i, your auto pip policy, state employee health plans, vets health system, the rules requiring hospitals to take anyone, nonprofit health trusts, nonprofit health insurers, and for profit health insurers …..you know, insurance IS socialism in a sense, right? collective risk pooling?
Sheesh. The premise that we need to talk about costs and benefits is true and all denial of this is mere ostrichization.
Wilful ignorance of costs has a name, actually, it’s called “balance denial” as when we fear looking at the check book balance and keep writing the checks anyway.
22
We could let everyone pay for their own health insurance.
The government or employeers don’t pay for food, clothes or shelter- all vital needs. Why do we think someone else should pay for our health care?
More open discussion is needed about this. Terminally ill patients do not need every possible measure if their quality of life blows. And the doctors running up all these tests should be fined and kicked out of medicine. They should only be treating the main illness. Pap smears on an 80 year0old-woman dying of cancer is just moronic.
My sister controls my living will and durable power of attorney. She is a cardiac care nurse. She sees everyday what you saw in that report. Families doing everything possible to keep a parent alive- a parent that has been in a coma for months and is never coming out. The family insisting on CPR to a patient who skin is literally falling off if they touch her. People in constant pain being subjected to continued life by their family who cannot say good-bye.
This sister knows to pull the plug on me if I have bad quality of life. She will insist on DNR. My whole family has these discussions and none of us want to be kept alive like that. (Well, except my religious, republican sister- go figure.) What these sicand dying people are put through is criminal. At some point somebody has to let them die with a little dignity.
Bottom line is that if insurance, any insurance, keeps covering medical extravagance like this, we are going to have an economy roughly as sound as Greece’s within the the next 20 years. It’s simply not sustainable.
There are any number of solutions, but they all involve coming up with standards of care, covering some basic standard fully and having patients pay for anything beyond that, perhaps up front.
We already use diagnosis edits to decide what proceures are appropriate for a given diagnosis, and insurance typically will not pay for procedures that fail those tests. So we simply extend that concept to cover a broader range of procedures and tie the conditions not just to diagnosis but to basic health and some objective standards of viability.
It’a not about being cruel or even callous, it’s about restoring rationality to medical care payed for by others.
The basis for universal healthcare is the sentiment that sickness is a fate that can befall anyone, and that were oneself or those close to oneself to be struck, we’d want a safety net in place. But the sentiment only applies to the extent that what we are paying for is rational. I would not want this sort of *care* for myself or for anyone close to me, and I’m appalled that I’m forced to pay for it, forced by the government, but also forced by the insurance oligopoly.
@26, 27, others:
This article, and its comments, are interesting to me not just because it alludes to the conversation Americans should be having about end-of-life care. I think it also sort of provides an insight into the position of Northwesterners on this complex debate.
Of all of the odd – and often unique in America – political concepts that dominate the Pacific Northwest (among them almost religious environmentalism, etc.), the most fascinating might be the legally-embraced concept of “death with dignity.” Only Washington and Oregon have “death with dignity” statutes, and I think this article is one of those that hints that there might be something more to that than the depressing weather.
There might just be, somewhere in the subtext of this analysis, a complex philosophical realization that there’s more to life than simply the material beating of a heart or the process of respiration.
It sort of reminds me of that one line from the Blue Scholars: “Not everybody lives, but everybody dies.”
@4, the question posed to the doctor is so full of fallacies it’s not worth answering “truthfully.” How about you don’t answer for him?
Maybe answer is something more like “I don’t believe in pulling the plug on Grandma, but I do believe in making the end of her life as full of dignity and without pain as possible, and that does not entail all the shit we do on/for these people right now.”
No one is advocating just turning away and quitting (nod @ 10), but looking at the long term outlook for each patient. It’s not about rules, it’s about talking to the family and balancing the odds. If 10’s grandma has a very treatable form of cancer and wants to treat it, then by all means do so, but accept the costs…and the realities that it may only add five years onto life, rather than 30.
As one of the CBS commenters pointed out, this is why end of life directives are so important (and why the health care reform bill needs to require or help provide them). Most people do not want heaps of unnecessary procedures, but they don’t make their end of life wishes explicitly clear so medical facilities (since they are a for profit industry) pile it on.
I also think this is very much tied into preventative and mental care. We focus entirely on the medical procedure, on fixing us like broken machines, rather than our health as a whole.
My husband works for a non-profit health insurance company, and this subject is huge. The cost of end of life care is huge. I think that we need to start having “end of life” discussions and have those discussions be a part of patient care, hopefully we can remove some of the fear of death, as we can’t avoid it and all of us will die.
Of course, these situations are not as simplistic as we would wish. (“Your grandma is going to die in exactly 12 days.”)
A lot of decisions are extremely difficult, because every cancer is not a death sentence, and everyone who is 70 years old is not an unproductive burden on their children and society. Many of them want to fight for their lives, to see their grandchildren grow up, or to even keep working.
It’s easy to use extreme cases as examples of abuse (as Republicans have always done with welfare fraud, etc.). But those don’t do anything to further reasonable discussion of the problem.
@26 You would think that your “religious, republican sister” would not want to fight death, wouldn’t you? Isn’t heaven waiting for her?
One of the issues here is the way that we, as a society, have made death a taboo subject. We think of death as the enemy rather than accepting it as an inevitable part of our lives.
@19
One point for “little one.”
minus 2 for being either:
a. A giant douche bag that’s independently wealthy enough to provide for 100% of their own health care.
b. not a giant douche bag that does believe what they write, and plans to commit hara-kiri at a moments notice in the event you are ever given a terminal prognosis. (and will pay for the clean-up.)
c. A troll that’s still too young, smug and idealistic. . . who just wants to win “at internet.”
@33 The funny thing is that with people I talk with, religious Republicans tend to be the most likely to do anything to extend life- see Schiavo. That brings me back to the argument of whether people are very religious because they have true faith or because they are just so scared of death they are really trying to believe that there is something else. I tend to think many people are religious just because they are scared of death.
@25:
“On what planet do you spend most of your time?”
“Trying to have a conversation with you would be like arguing with a dining room table.”
(Thanks Barney!)
Thank you, root @22, for keeping my head from exploding and bloodily decorating the office. These Darwinian assholes who think only of themselves and not the society they live in deserve to be rudely dismissed at every turn.
Unless more data about that $50b is hiding somewhere, the number is useless. What’s missing is data on the average effectiveness on the procedures constituting that $50b. Without it, we can’t determine whether it was a bad investment or a good one that just didn’t pan out.
@29-absolutely. the life expectancy discussion was a part of whether she should even start treatment. i think it is valid point to make. thanks for bringing it up.
@36,
There’s a study out there that proves it. Religious people invariably demand extraordinary life-saving measures while nonreligious people accept what’s happening and spend their last days with their loved ones.
In what world does this doctor live in where the elderly get organ transplants? Organ transplants are pretty much the only medical procedures that are highly rationed, and elderly people and the mentally disabled need not apply.
Birth is often treated the same way by big medicine — heaps of tests, drugs, medical procedures — when in most cases it can be a low-intervention, natural process…at home with a midwife rather than a massive hospital experience. Although everyone I know has gone the hospital route, and I probably would, too. I’m a chicken.
If pulling the plug on grandma allows the system to afford useful preventative treatment for a thousand infants, then grandma’s got to go. These calculations should be based on years of useful life left. Kids, who are currently last in line for just about everything, should be first, since saving a kid’s life results in 50, 60, 70, 80 years of additional useful life. Adding six months to grandma’s life costs a fortune and provides very little benefit.
These people like that doctor never talk about the life that could be saved elsewhere. And they’re usually just trying to protect their own income; a heart surgeon is keenly interested in getting as many heart surgeries paid for as possible, but doesn’t give a shit about natal care.
My grandmother always used to say that when the Lord’s angels come calling at the door it’s arrogant and selfish to not heed the call. Many times, and you especially see this with wealthy folks and in the new life extending researches being done we humans become so rooted in this world, in the physical, that we completely forget (at least those of us with the knowledge) that there’s more to this worldly aspect for our souls. If you are aware of this truth upon reaching a certain age then you are more likely to let go of this earthly realm, embrace the afterlife that’s waiting for all of us and not fall in what basically amounts to a dehumanizing life, substained artificially in many cases by a machine. Doing away with human life is akin to believing one is God but so is extending it beyond it’s natural years and time.
@44:
If that were truly the case, then how do you explain @41’s assertion (I presume this is the article to which they are referring) that believers are more likely to demand expensive, and ultimately ineffectual, life-prolonging medical care? Why don’t they simply acknowledge their mortality and accept the embrace of those angels?
Couldn’t possibly be due to a last-minute loss of faith now, could it?
@45 Regarding euthanasia, those that believe in the existence of God have to thoroughly reject such practices but if you’re referencing to prolonging life in old age thru artificial means when the soul clearly seeks release from the physical prison, then, you are certainly correct in stating that those of faith that hold on unto a machine instead of embracing the afterlife and in the case of Christians, the loving arms of our Lord Jesus Christ, have clearly either not have a well grounded understanding of the message and promises of a better life by the side of our Lord or have forsaken the heavenly abode and are trying desperately to cling on to what this mundane world of suffering has to offer. It can and has happened especially to those who have amased material wealth, even if they proclaim to be Christian, but it has to do more with them not wanting to leave their worldly status than it does with a flaw in Christianity which is what i believe you’re trying to imply in your comment. Jesus while on this Earth in his human form was very clear concerning such persons:
“I tell you the truth, it is hard for a rich man to enter the kingdom of heaven. Again I tell you, it is easier for a camel to go through the eye of a needle than for a rich man to enter the kingdom of God.” Matthew 19:23-24
Nothing in the article, which presumably you didn’t bother to read, mentions ANYTHING about the income levels of the terminally ill patients studied. So, your assumption that they MUST be wealthy is based on nothing, aside from your belief that this MUST be the reason they cling to life, even though, as usual, there’s no evidence to support such an assumption in the first place.
Maybe they cling to life because, in the end, they realize THIS life may in point of fact be the ONLY life, they’re scared shitless by the prospect of oblivion, and will do anything, take any measure necessary to stave it off for a few more days or weeks.
You know the old saying, “there are no atheists in a foxhole”? Well, this seems to be the counter: “there are no believers in a terminal ward”.
As a student in a well regarded RN program I’ve been surprised to learn that we already have standard of care. They are called “critical pathways” and they are developed by hospitals so that they can justify their expense to insurance companies, and so that they can defend themselves against pt lawsuits. It is emphasized over and over again that we as nurses must chart (document) that each step has been preformed as specified for the pt’s admitting diagnosis, not because this is the best pt care, but because it allows thehospital to be reimbursed, and it allows hospital/MD’s to cover their asses.
We need standards of care determined with Pt welfare, pain reduction, cost/ benefit in mind, not profits/ legal defense.
@45 That article which shows a correlation between religious belief and attempts to extend life using any means possible tends to support Penn Jillette’s belief as a hardcore atheist: “I don’t believe that they really believe.”
I think many people are religious only because they are scared, even terrified, of death. I doubt they really believe they are going to heaven, or there is one.
48
Nursling raises an interesting and usually ignored point about the true cost of defensive medicine and the true savings possible from tort reform-
Democrats cite the actual amount paid out in malpractice claims and declare that it is not all that much and hence there is little upside to or need for tort reform.
They miss (or ignore) the true costs, which is not in the cases that lawyers become involved with or that go to court- the true cost is the added uneccesary treatments and tests that are routinely performed on each and every patient just to cover some doctor’s or hospital’s butt.
No one who knows will detail it for you because it is an admission that something other than best interest of the patient drives health care decisions but anyone who actually is a decision making healthcare provider could tell you that every aspect of care is (negatively) affected by fear of tort.
Meaningful tort reform that installed a means to actually deal with substandard care in a way beneficial to patients (and providers) as opposed to the ‘lottery jackpot’ system we currently have would result in sweeping changes in the way health care is delivered.
I thought the piece was great. Good hospice care of at end of life would produce much better deaths and reduce the costs of care for everyone. Anthony’s point about loopholes seems totally on the mark. We need to learn when it’s time to prepare for the next stage of existence and stop clinging to this one.
Often times it is the family and not the patient making the decisions on end-of-life issues. And quite often, those decisions are for selfish reasons. My logic has always been that when the quantity of life exceeds the quality of life, it’s time to go. I hope that whoever is making the decisions at the end of my life follows my wishes. I hope people stop thinking “I don’t want X to die” and replace it with the thinking “I don’t want X to die in a hospital, unconscious or suffering, hooked up to a bunch of machines.” These are not “end grandma’s life” issues. These are “respect grandma’s life and death” issues. (Oh, and yeah, wtf with the 80-yr-old pap smear???)
@11- You’re either rich and selfish or you are very dumb.
@25- Collectivizing health costs significantly increases the value people receive. Not so with food, etc…
@46- “Regarding euthanasia, those that believe in the existence of God have to thoroughly reject such practices…”
No they don’t. What an amazingly flawed premise.
my husband worked in Cardiac medicene for 20 yrs. and it is unbelievable how many people just want their loved ones kept alive even when they know they will never be conscious again. I think for a lot of people it is just trying to delay grief as much as possible. For others I think they believe they are showing other family members their love and devotion by keeping gramps alive at all costs. But you can always tell the ones that know they are in the will, cause they have their eye on the electrical outlet visualizing that plug being pulled out. Thank God for these sane family members or we’d never have any empty hospital beds!
@ 55, you are absolutely right. I have had so many patients treated like possessions or keepsakes by their family. “I don’t want to feel like I killed her.” Really? That’s great, but are you considering what she would want? People put their feelings and comfort first, and blow off their loved one’s pain.
As for 80 year old pap smears in someone with a “do not resuscitate” order – guess what? “Do not resuscitate” does not mean “do not treat” as any trial attorney can tell you. If you have vague living will about ‘avoiding needless or painful medical treatments should my condition become irreversibly terminal,’ blah blah, you’ve put your physician in a tough spot. Most of these crazy expensive tests are done before it’s irrefutable that the patient is about to die and their life cannot be significantly extended, however unlikely it may seem. All it takes is one crazy relative to drag you into court, and then you’re faced with something like this:
ATTORNEY: Dr. X, did you screen Mrs. Y for cancer the way you would for any other patient?
DOCTOR: Well, no, I did not perform the pap smear out of respect for the patient’s stated request to avoid medical testing for a terminal condition.
ATTORNEY: But Dr. X, how do you KNOW her condition was terminal if you didn’t do a complete cancer screening?
DOCTOR: It’s common sense that a patient 80 years with extensive cancer has little chance of survival, and it seemed like the test wouldn’t make a difference.
ATTORNEY: “Little” chance, Doctor? That’s not the same as no chance. There ARE cases of the elderly developing cervical cancer, and you didn’t even consider the possibility. Mrs. Y deserved that “little” chance that you didn’t even bother to give her. Isn’t that your JOB, doctor?
And then you’re fucked. Everything you worked for for so long, that your family sacrificed for, gets taken from you.
Sorry, but if there’s any vagueness about a living will or Do Not Resuscitate document, the doctor is “supposed to” take the most aggressive approach permitted by the documents. It sucks, we hate it, but asking us to put our necks on the chopping block to save society money when society itself (and the patient and their family) aren’t willing to make the tough decisions isn’t realistic.
@56 – Agreed. Doctors should absolutely not be put in this situation. We need frank and open discussions about how people want to die, and clear and direct living wills should be commonplace if not required.