Author: cmh

Forum: Before you die, speak up

Forum: Before you die, speak up:

I am an intensive care physician. My days are mostly spent working with a dedicated, caring team resuscitating people from septic shock and respiratory failure back to health.

Unfortunately, many of our patients, already near the end of life with serious advanced illnesses, would not want and will not benefit from these heroic measures that we’ve inflicted on them — but the paperwork and orders necessary to prevent them are not in place.

In these cases, we work, a bit too late, to put things right and to do right by these people who entrust us to do our best for them. We are privileged to help those who will get better and to comfort those who will not. But we can do better.

I wrote this a few years ago, but it has become pertinent again along with these pieces written by Gary Rotstein, health reporter for the Pittsburgh Post-Gazette:

End-of-life questions often go unasked

Disabled worry lives not valued

So now, they are bookmarked in the blog.

UPDATE: two recent op-eds in the Pittsburgh Post Gazette of note:

The last days of our lives: Our health-care system needs to provide better, more thoughtful end-of-life care.
Wednesday, August 26, 2009
By Dr. Robert Arnold and Nancy Zionts

Sunday Forum: Forget the euthanasia talk — end-of-life care is needed
It’s time to debunk the misconceptions about provisions in the health-care reform bill, says RAFAEL J. SCIULLO
Sunday, August 23, 2009

George Lakoff: The PolicySpeak Disaster for Health Care

George Lakoff: The PolicySpeak Disaster for Health Care:

The narrative is simple:
Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.

The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.
Language
As for language, the term ‘public option’ is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that’s what it really is.
The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It’s got conservative veterans at Town Hall meeting shouting things like, ‘I fought for this country in Vietnam, and I’m fight for it here.’ Progressives should be stressing the patriotic nature of having our nation guaranteeing care for our people.
A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. 50 million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can’t wait any longer. It’s an emergency. We have to act now to end the suffering and death.
Doctor-Patient care. This is what the public plan is really about. Call it that. You have said it, buried in PolicySpeak. Use the slogan. Repeat it. Have every spokesperson repeat it.
Coverage is not care. You think you’re insured. You very well may not be, because insurance companies make money by denying you care.
Deny you care… Use the words. That’s what all the paperwork and administrative costs of insurance companies are about – denying you care if they can.
Insurance company profit-based plans. The bottom line is the bottom line for insurance companies. Say it.

Private Taxation. Insurance companies have the power to tax and they tax the public mightily. When 20% – 30% of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96% of voters that
have health care. But the tax does not go to benefit those who are taxed; it
benefits managers and investors. And the people taxed have no representation.
Insurance company health care is a huge example of taxation without representation. And you can’t vote out the people who have taxed you. The American Plan offers an alternative to private taxation.
Is it time for progressive tea parties at insurance company offices?

Doctors care; insurance companies don’t. A public plan aims to put care back into the hands of doctors.
Insurance company bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.

Insurance companies ration care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does
you primary care physician have to rush you through? Have your out-of-pocket
costs gone up? Ask these questions. You know the answers. It’s because insurance
companies have been rationing care. Say it.
Insurance companies are inefficient and wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.
Insurance companies govern your lives. They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.

The health care failure is an insurance company failure. Why keep a failing system? Augment it. Give an alternative.

Health care reform: What is costly overuse, what is humane?

Health care reform: What is costly overuse, what is humane?:

This is the piece Betsy McCaughey read from on The Daily Show last night, regarding EOL care and the horrors of HR 3200.

“My problem, as a physician who has practiced medicine for decades, is that I just can’t predict with certainty what is end-of-life care, nor can I determine for another individual the meaning of ‘quality of life.'”

Well that’s the whole point, isn’t it? It s not the physicians choice it is the patient’s choice, the patient’s wishes that count. It is entirely the point of advance care planning and advance directives that it is up to the patient to decide what he or she wants. Our responsibility a physicians is to give them the best information that we can, imperfect as it is, and help them come to decisions that best reflect their wishes and goals.

And, no, we cannot predict with certainty when a person is exactly at the end of life – and I suspect that this author and Ms. M. would only except a definition of end of life as minutes away – but I do have a wealth of experience to go on, and I think it is unprofessional to allow families to cling to miracle scenarios for survival.

And here’s another gem:
“I would be loath to talk a person on dialysis or in a wheelchair from a stroke into forgoing antibiotics for a pneumonia that may itself be treatable.”

Well, so would I, because that is not the role of a physician, is it? Jeebus. Jude the Obtuse.

Ms. M. read this part:
“These and other provisions of the health choices act frankly scare me. As a physician, I took an oath long ago to put my patient’s interests above all else, but provisions in the bill have a quality of coerciveness that make me wonder if I can fulfill my oath.”

You have a higher duty to be honest with your patients and not blow smoke up their rears, telling them that this next chemo, this next procedure, this next indignity, is always worth it.

As I’m putting together this post, it infuriates me to consider countering this stupid, stupid, stupid, uninformed, heartless, obtuse rhetoric yet again.

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform | Video Cafe

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform Video Cafe:

“Isn’t it amazing what a little clarity to your argument can bring you isn’t it? Like arguing for real reform instead of the mushy middle. Anthony Weiner did a fantastic job on Morning Joe today and he actually left Scar speechless for a moment when trying to get him to answer just what the insurance industry does to benefit anyone. Of course Scarborough turned that around into ‘You’re arguing for a government takeover of health care’ shortly afterwards, but he never could give any decent defense of why this country needs the insurance industry.”

From Crooks and Liars, what a great video! An articulate advocate for Single Payer.

I’ll ask the question again: What value do private insurers add to health care?

Survival for $25,000 – TIME 1971

Survival for $25,000 – TIME:

This is an article about the trials and tribulations kidney failure patients faced before Medicare expanded in 1972 to cover kidney diseases theough its End Stage Renal Disease (ESRD) Program.

At 29, Don Shevlin was just two months away from taking his oral exams for a Ph.D. in English at U.C.L.A. Today, two years later, he has neither the degree nor any prospect of a teaching job. Says he: ‘I see myself as perennially pauperized.’

Shevlin suffers from chronic kidney disease, an incurable type that necessitated the removal of the organ. Now, in order to prevent a fatal buildup of toxins in his blood, he must report to the university hospital three times a week for kidney dialysis, a six-hour cleansing process that enables him to survive until he can get a kidney transplant. Since his illness wiped out his small savings, Shevlin lives on welfare payments of $178 a month, while the State of California pays for most of the cost of his treatments —which amounts to $3,000 a month.

Shevlin’s position is not unique. Nearly 5,000 Americans are currently undergoing regular kidney dialysis. Thousands more would choose such treatment if it were more widely available, but none can escape the gigantic cost of staying alive.

One of the questions I get asked is, “Aren’t you worried that ‘The Government’ will take over and start cutting off care or rationing care?” Not under Democrats.

Medicare and the ESRD program are examples of America’s liberal social justice tendencies accomplishing something.

Too bad kidneys aren’t the only organs that go bad, or we’d already have universal health care.

DrMatt: I’m worried about the death panels…seriously…

Over at DailyKos, DrMatt has collected a nice selection of anecdotes for my collection.

I have some more from Doctors for Amercia I’ll try to post later today…

I will be on KDKA Radio Pittsburgh tonight (Thursday Aug 13) at 9 PM with conservative talker Mike Pintek.

You can listen live at www.kdkaradio.com

Cheers,

IBD, Stephen Hawking and Nice

You have by now all read of the very funny folks at Investors Business Daily thought England’s NHS was so awful that a poor soul like Stephen Hawking would be long dead had he to depend on those slugs in England for his care.

Just in case you missed it, here’s the correction:

Editor’s Note: This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the UK.

But, enough hilarity. If you read the rest of IBD’s editorial, you might notice their attack on England’s National Institute for Health and Clinical Excellence (NICE), an arm of the NHS, for its ruthless analysis of the cost and effectiveness of drugs. The bastards!

Anyway, the editorial contains this sentence, “In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer.” This is interestingly the exact same sentence that appeared in a WSJ op-ed on July 7th. But it’s a beautiful sentence. Who can blame IBD?

IBD also has this gem: “The British are praised for spending half as much per capita on medical care. How they do it is another matter. The NICE people say that Britain cannot afford to spend $20,000 to extend a life by six months. So if care will cost $1 more, you get to curl up in a corner and die.”

I can just see the clinicians and scientists at their final meeting, throwing patients under the bus for that dollar/pound. Bastards! The corollary to this, when you think about it, is the pharmaceutical company not lowering the price for the wonder drug by this apocryphal dollar. Bastards!

But what about these heartless beasts at NICE and these wonder drugs the British public is being denied.

From the NICE report on Lapatinab for breast cancer:

Clinical Benefit Rate
Using the independent assessment a greater proportion of subjects in the lapatinib + capecitabine group (29%) than in the capecitabine group (17%) achieved clinical benefit (odds ratio: 2.0, 95% CI: 1.2, 3.3, two-sided p-value: 0.008; cut-off date 3 April 2006). Using the investigator assessment of the clinical benefit response rate a greater proportion of subjects in the lapatinib+capecitabine group (37%) than in the capecitabine group (21%) achieved clinical benefit (two-sided p-value: 0.001).

Duration of Response
For subjects who responded to treatment, the median duration of response was 32.1 weeks in the lapatinib+capecitabine group and 30.6 weeks in the capecitabine group.

Get that? They are being denied a drug that increases the median duration of response by a staggering 1.5 weeks for the additional 12% who had some response to treatment!

The same paper included an analysis of a study on brain metastases that showed no significant difference in outcomes there, either.

Don’t get me wrong. I am all for research and pushing the envelope. Continuing to study these drugs is fine, as long as all the appropriate ethical guidelines are followed, particularly with regards to real informed consent. But arguing on the basis of a study as described above that this should be placed into mainstream use is ridiculous.

My other pet peeve about these types of treatments is the cruel, false hope given to so many patients as they are offered “the next” chemotherapy regimen, intensive care, and so on.

I also have no objection to choosing to continue these treatments to the bitter end, as long as one understands the choice. I often get patients on “salvage” chemotherapy, palliative chemotherapy or palliative radiation treatments who don’t understand what those terms mean. Maybe they were too rattled when the discussion took place and simply don’t remember. But my experience with these patients and their families is that the discussion never took place in earnest.

Being told that the cancer has come back or spread to your brain or whatever and that here’s what we can do next is far different than having a really hard conversation about your prognosis and all of your options.

Maybe your options are 2 or 4 or 6 months with “salvage” chemo if things go well (or a much more abrupt end if they don’t!) versus 1 or 3 or 5 months without, but at home, having your symptoms aggressively managed by a palliative care specialist and working with hospice for a peaceful dignified end. And more than likely the 2 or 4 or 6 months with aggressive treatment means a lot of that time spent in the hospital, dying in an intensive care unit, hooked up to life support until someone finally tells you, too late, the hard truth.

Let’s not kid ourselves about this disturbing side of American medicine: our often mindless devotion to doing “everything” up until the nails are being hammered into the coffin is, more often than not, in stark contrast to doing “the best things” for our patients.