Thursday, December 17, 2009

THE REAPER BATS LAST



On a run this morning, I met an old friend. “Old” means he’s older than I am.

He said, “My wife and I have been struck by how many people we know are getting seriously sick or dying. I guess it comes with aging. Anyway, we’re beginning to talk with each other about our own deaths. You know—wills, powers of attorney, unfinished business.”

Good for them. And good for me, too. We’ve been discussing death and dying in our family for years. I’ve seen again and again that keeping it taboo begs trouble: family donnybrooks at the bedside, recriminations, litigation, misery no one needs.

Some part of each of us, I think, has bought into the notion that space-age medical intervention can snatch us perpetually from the grave. Add to that our personal, built-in, lifelong, tenacious denial of death, and little wonder we come to feel, however irrationally, that we’re entitled to immortality. William Saroyan’s last words were, “I know we all have to die, but I thought maybe in my case they’d make an exception.”

So it is that we conveniently ignore that The Reaper bats last, and direct our healthcare practitioners to apply heroic measures at the end of life, especially when we don’t pay for it ourselves. Medicare, the health insurance program for the elderly, spends nearly thirty percent of its budget on beneficiaries in their final year of life.

People who are dying are sicker than other patients, so spending more on their care is understandable. But for most reasonable purposes those efforts are futile, and predictably so. Medical science can indeed prolong life, but that too often amounts to prolonging suffering. In palliative circles, practitioners discuss this metaphorically, asking “whether the game is worth the candle.” In actuality, there’s usually no game left at all, since attention focuses exclusively on just trying to keep the candle lit.

Talking in advance about death and dying issues makes a tangible difference. Reporting last March in the Archives of Internal Medicine, investigators interviewed 603 advanced-cancer patients about whether they’d had end-of-life (EOL) conversations with their physicians. The researchers calculated the final week’s healthcare costs of patients who’d had such conversations, and compared them with the costs incurred by patients who hadn’t.

Those who’d had an EOL conversation had an average of $1,876 in health care expenses during their final week of life, compared with $2,917 for those who hadn’t, a difference of $1,041, or 36 percent. Higher costs—typically the result of more intensive, life-prolonging care—were also associated with a worse quality of life during patients’ final week. In addition, patients typically did not live longer if they received more intensive care.

Let’s go over that again: extreme medical intervention evidently results in lower quality of patients’ remaining days, doesn’t actually extend their life, and is hideously expensive. Wow, where does the line form?

A couple of months ago, I asked my cancer support group whether everyone had a Durable Power of Attorney for Healthcare. They all did, but I found to my chagrin that I couldn’t find my own. So my wife and I hustled up some new ones. We each named the other as our primary agent, authorized to make medical decisions if we're incapable.

Choosing an agent can raise fascinating questions. I imagined myself in an ICU bed, for example, apparently comatose but actually able to hear. My doctor tells my wife we’re in the home stretch at this point, so asks for her orders—whether to do even more, or, as popular terminology has it, “pull the plug?”

She answers the doctor, and I think, “Whoa! Wrong decision.”

But of course, I’m unable to speak. Scary.

But wait a minute. How do I know she’s made the wrong decision? I can’t know that I’m “right,” whatever “right” means; I know only my preference. Since I have nothing else to do at that moment, I review our history together. How many times has her judgment been superior to mine? Pretty damn often, actually. Haven’t I learned to literally trust her with my life? In addition, when, after all, can I simply let go?

Questions like these can elicit emotion and sometimes argument. They’re plenty meaty, extending as they do from the ultimate source of most fears, death. No wonder we shy away from them. One indication of how fearsome the subject can be is that in one national healthcare reform proposal, doctors would be paid to have EOL conversations. Many Americans came unglued at the prospect of discussing death, and chose to interpret the proposal's provision as "death panels."

Though doctors are increasingly trained these days in end-of-life issues, many don’t routinely initiate conversations in that area because, frankly, they’re not paid to do so. They get paid for procedures—spinal taps, liver biopsies—but not for just talking with patients. Paying doctors to hold these conversations would save millions if not billions of dollars and an untold amount of needless suffering.

Authentic healthcare reform then, needs to acknowlege, appreciate and address our widespread fear of death and dying.

2 comments:

  1. Yes, and so we have Sarah Palin's brilliantly demagogic phrase, "death panel." Death is a phase of life, albeit the final one, and needs to discussed by people like the other phases of life. The prime medical directive of "do no harm" should still apply to people in the final stage of their lives. This directive is violated by health practitioners, if life is prolonged by end of life treatment with resultant suffering, that is contrary to the will of the person. The fact that most people want to spare the animals they love of suffering during the final stages of life, should at least make them aware that this is an issue they may need to address in the lives of persons dear to them, and in their own lives. They could do this through the health care directive which asserts the finality of the patient's own will, in their own treatment plan --- through the informed consent document, a process which Jeff describes.

    Jeff Kane also describes here, the huge financial costs associated with end of life maintenance .As he writes in this 12/17/09 blog entry, "Medicare, the health insurance program for the elderly, spends nearly thirty percent of its budget on beneficiaries in their final year of life." This intensive medical care (so called extraordinary or heroic care) for the terminally ill , could be replaced with palliative care. Then, physical life and quality of life could be maintained at less financial cost, with a minimum of human suffering.

    This might also enable patients to leave their financial nest eggs -- which they might have spend years building-- to their heirs, and not to the medical establishment. Indeed, in this generation, a whole new transfer of wealth paradigm has emerged, from heirs to medical establishment. We need informed consent, by the patient, to the end of life options that they wish.

    So, how about this slogan, Sarah Palin:
    "Say 'no", to financial gain
    That is bought by patient's pain,
    in the end of life treatment game.
    The patient's informed consent
    puts a dent
    In that game plan."

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  2. dear Dr. Kane,
    I liked both the last postings, but I liked this one especially. Matt Zwerling introduced me to you. We will "hope and pray" that more EOL conversations happen in a timely fashion. One of the things which appalls me is the need to code visits as if they were tune-ups at the mechanics'-- and we will charge this much for your new muffler. When you ask me how long these tires should last, or whether we may need new spark plugs, I will tell you to check back in a certain time-span or number of miles. The built-in conversation we should be having about end-of-life care hangs on "the doctor-patient relationship"-- sort of like what happens when the mechanic and the owner of the car stand around the engine, talking. The conversation may touch on various things-- and not be easily quantified or coded. And with luck and grace, it should deepen over time, so that the patient trusts the physician, just as you say you would trust your wife to help make a "right" decision for you, as a durable power of attorney function.
    As a physician, I feel degraded by having to code for visits, and to find reasons which are not psycho-social in origin, to "cover" the real work I do. I believe I am putting the patients' concerns and sufferings into a context. I often give advice about what to do with a spouse who is ailing, or a child who needs something sophisticated in social or education, or mental-health care. I advocate for self-care. I talk about bones and heart health. We talk about "aging gracefully" and what that means to us. So I code this under a normal annual GYN exam, and extra code for additional preventive care conversation-- which pays a little more. I am worried that these codes now take away the patients' privacy from the insurance company. I cannot understand how the HIPPA got so twisted, that the family cannot know what is going on, while a huge pipeline of information goes to the pharmaceutical companies and the insurance companies with those codes.
    Thanks for being so intelligent about the EOLC conversation. I hope doctors will get paid to talk sanely (healthily!) to patients about dying. I hope these conversations will also be paid for when it includes the extended families.

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