A quandry involving Medi-Cal, going from paying badly to not at all

[Pazuzu]

Originally Posted by Nathans_Dad

This is basic medical ethics, people who believe that doctors exist to prolong life at any cost are exactly the reason why we have the situations detailed in this thread.

Color me the cause then.

How much of a strain is it REALLY on a hospital or doctor to give exceedingly futile care to a terminal patient? How often does that happen in a year vs. the other cases? Is it bankrupting hospitals? I am one of those fools that thought that doctors tried to do anything in their power to keep someone alive as long as possible, and if that meant a $50K hospital stay for their last 4 days on this planet, then so be it. Foolish me.

[Nathans_Dad]

Sorry man, your idea of what doctors do is not correct in any sense.

To keep people alive "as long as possible" at any cost, no matter what the outcome to patient isn't medicine....in many ways it is simply torture.

Doctors try to heal people, we try to return them to their lives.

We also must realize that death is a part of life. We cannot stave off death forever nor should we. It is not right or ethical to keep someone's body alive using artificial means when there is no change in the outcome, nothing to be gained.

I really can't say it any other way. Sorry if it offends you, but it's the truth.

[Pazuzu]

Your first iteration of that post was better.

[Nathans_Dad]

Well, I thought it was a little harsh so I decided to try again.

Kindler and gentler.

I am curious to figure out why it is that you have the belief you do. Do you not see the problem with keeping someone alive at all costs? How long does that go on?

It's strange to me that a decent portion of the public seem to have such a radical view of what a doctor's mission is. You aren't the first person I have heard talk this way (well, actually you are the second). The first person was the daughter who insisted that everything be done for the patient in the example I mentioned. I talked to her for over an hour with the hospital chaplain present and made no headway whatsoever.

Her rationalization for keeping her mother alive even though she was obviously suffering needlessly was that she believed that God uses suffering to teach people things. She said that since Jesus suffered before he died, then her mother would suffer until "God decides to take her". I tried to explain that without artificial means of life support she would have died days ago...but that didn't get anywhere.

What's your reasoning?

[Noah930]

Pazuzu, I'd opine that the vast majority of doctors would lean towards Nathans Dad's view of medicine, as opposed to yours. The point of being a doctor is to help people. At different stages in life, that means different things. The concepts of "success" and "failure" are not necessarily tied to the strict determinations of "life" and "death."

And, yes, it's unreasonable to expect that spending $50K for futile care on every person's last 4 days of life should be considered a sustainable economic system. In a busy hospital, things like this go on on a daily basis. Clearly not with every patient. But there will be someone (or a few someones) on any given day in that scenario.

[Tobra]

Hey, where did my post go where I asked Rick why he deleted the same post Mike thought was better worded.

I totally harshed on Mr Bradshaw, well not totally, but I did indicate he needed to read more carefully, think more critically, now it is gone, all gone.

This stuff happens every single day, in every single hospital in the country, so yeah, it happens a lot.

[Hugh R]

Originally Posted by Pazuzu

Color me the cause then.

How much of a strain is it REALLY on a hospital or doctor to give exceedingly futile care to a terminal patient? How often does that happen in a year vs. the other cases? Is it bankrupting hospitals? I am one of those fools that thought that doctors tried to do anything in their power to keep someone alive as long as possible, and if that meant a $50K hospital stay for their last 4 days on this planet, then so be it. Foolish me.

Certainly not a doctor, but you'd probably have a different view if you were getting the money taken directly out of your wallet for someone else's 87 year old grandmother whom you've never met. You're spending other peoples money in the form of taxes and higher medical costs that you don't think you actually pay for.

[Pazuzu]

Originally Posted by Nathans_Dad

It's strange to me that a decent portion of the public seem to have such a radical view of what a doctor's mission is.

I had a response to your harsher post, and deleted it, feeling that there was no reason to continue this discussion.

However, it basically said that us (the non-initiated ) do not know what decisions and what ethical guidelines doctors work under. We hear of "Do No Harm", and assume that it is a vital guide for you. When doctors then say that, no, it's not at all like that, we wonder. However, rather than explaining to us, they get defensive (as you did). We also don't really know how big of an issue those terminal 87 year old grandmothers are. I asked you, but you glossed over that part. Does this happen daily in each OR? Does it cause financial hardships for hospitals? Or does it just happen enough to be a point of discussion every now and then?

Also, I think that in your position, you become hardened against death. Me? Not so much, and I would be pissed to think that a doctor didn't do everything to keep me alive for another 3 hours or 3 days or 3 weeks...because, well, it's kinda all that i have. Therefore, I need to keep that idealized view of doctors in my head, and I have to assume that they will act the way I expect them too in my idealized view, rather than acting in the rational way that they probably will.

[jyl]

TV can't help. In medical shows, the doctors move heaven and earth to keep patients alive for every possible minute and no one ever pays a bill.

[Noah930]

"Do no harm" is part of the Hippocratic Oath, to which all doctors swear. However, I think it means different things at different times. Prolonging/extending life at all costs (literally and figuratively) is not necessarily in the best interest of the patient. Maybe it's better to let a little old lady, whose body is riddled with cancer, a chance to comfortably slip away to death on a morphine drip, than it is to keep her alive for as long as possible (another week, month?), with a lot of tubes and procedures, and where every conscious moment is spent in pain. Happens on a daily basis in every hospital.

Your point about wanting to live for as long as possible is also a valid opinion. That's why it's best to share these types of thoughts with your personal physician, and those close to you, so that if you're ever stuck in that situation and cannot communicate your desires for yourself, people know what to do. You'd be surprised at how many families agonize over these end-of-life decisions (probably at least 50% or more, IMO). For younger people, I can see how no one really takes death seriously, so no one really takes the time to outline their positions to family and friends. But it's hard for me to understand how people get to be in their senior years, yet still never have thought about these issues (or, at least, haven't shared their thoughts with their loved ones). WTF?

[Rikao4]

Mike, no-one gets hardened..or used to it..
we come to accept the possible / probable outcome..
I'm sure there are situations/ conditions ..
were you would want them to stop trying..
you would be 'alive' but YOU don't even know it..
to me that is not life..
so I will request express checkout ..1 item..1 bag.

Rika

[Nathans_Dad]

Originally Posted by Pazuzu

I had a response to your harsher post, and deleted it, feeling that there was no reason to continue this discussion.

However, it basically said that us (the non-initiated ) do not know what decisions and what ethical guidelines doctors work under. We hear of "Do No Harm", and assume that it is a vital guide for you. When doctors then say that, no, it's not at all like that, we wonder. However, rather than explaining to us, they get defensive (as you did). We also don't really know how big of an issue those terminal 87 year old grandmothers are. I asked you, but you glossed over that part. Does this happen daily in each OR? Does it cause financial hardships for hospitals? Or does it just happen enough to be a point of discussion every now and then?

Also, I think that in your position, you become hardened against death. Me? Not so much, and I would be pissed to think that a doctor didn't do everything to keep me alive for another 3 hours or 3 days or 3 weeks...because, well, it's kinda all that i have. Therefore, I need to keep that idealized view of doctors in my head, and I have to assume that they will act the way I expect them too in my idealized view, rather than acting in the rational way that they probably will.

Ok, so the flaw in your argument is that you are not acknowledging that keeping someone alive through artificial means with no hope of meaningfully prolonging their survival, i.e. keeping them alive for another 3 hours or 3 days or 3 weeks without any hope of meaningful survival...

That IS doing harm.

Your view of medicine is a vastly oversimplified, black and white view. Black and white never occurs in real life.

I didn't mean to "gloss over" the 87 year old grandmother question, but let me give it full attention now:

If you are asking how often we have patients in our hospital in the ICU, on the vent or other aggressive life saving equipment while they have a terminal diagnosis...I would say probably 4-5 times per month. That's for the entire hospital, not just me.

Now then, if you want to expand that idea, how many times do we have elderly, demented, nursing home resident, bed bound patients with bed sores who have no cognitive clue where they are or what is going on admitted for various medical problems that will not have any impact on improving their lives? All the time. As in multiple admissions daily.

If you are looking for impact nationwide in cases of truly futile care...well considering that it costs probably somewhere around $5k per day for an ICU stay, factoring in procedures, meds, equipment, nursing, etc. I would take a guess that we spend billions of dollars yearly on truly futile care in this country.

These conceptions are exactly what I was talking about in the beginning of the thread where I talked about changing the entire society.

[Pazuzu]

Lemme try to start over here.

I was a bit shocked by a doctor talking so callously about the effort put into a dying woman. I understand the financial burden put upon the hospital and ultimately the community, and I understand the feeling of defeat (perhaps for lack of a better word?) that the doctor must feel when he has to make these ethical decisions.

I guess that I was (1) surprised to hear a doctor say such a thing in a public forum (I'm sure they say it regularly amongst themselves, in private settings) and (2) a bit annoyed that instead of education us (the laypeople) on real world medical ethics, that Rick drove the screw to me instead. I know I can be a bit rough, but I honestly don't think I was in this case.

I'm sure that doctors have a set of ethics that is defined by their field, not by their hearts, just as any field does. Lawyers get crapped on for it, cops get crapped on for it, heck, even when I was an astronomer we got crapped on. In each case, the "internal ethical structure" that exists in that field is a secret to the rest of us, and might seem disturbing from the outside. I had an image of this "medical ethical structure" that was a bit idealized, and based around the Oath. It seemed that Rick's comments flew in the face of that, and that's why I asked if I was understanding his statement correctly.

So, instead of ragging on me give me a deeper understanding of how this ethical structure works. Where are the limitations on who gets what effort put forth? How does a surgeon make triage decisions? Do your personal ethics come into play, or is there no real room for that? Do you change your views on it ask you grow older in the field? Are there well defined, maybe even documented ethical guidelines (for example, does a 87 terminal patient get less care than a 65 year old terminal patient?)? Is the current discussions of health care reform changing the ethical framework of the field? Give me something to mull over, and I'll learn from the process and better understand when you doctor types get to *****ing about doctor type things here

[Noah930]

Originally Posted by Pazuzu

I guess that I was (1) surprised to hear a doctor say such a thing in a public forum (I'm sure they say it regularly amongst themselves, in private settings)

Not to rag on you, but that's a major part of the problem. The public's expectations do not match with reality. Meaningful change in healthcare delivery (and economic viability) is unlikely to happen until that occurs.

[Nathans_Dad]

I think you will get quite a bit of the way towards understanding medical ethics when you stop looking at death as a defeat. Death is a part of life. It is not a defeat, either for the doctor, the patient or the family.

I see my job as to heal illness when I can and when I cannot, to accept that and to help the person meet their end with dignity and as pain free as possible.

If I was callous about what happened to that woman, it was because what happened was 100% not in her best interests. She was incoherent and suffering. She was going to die within the next days or weeks no matter what we did. So instead of letting her drift off into oblivion from low blood pressure (not a bad way to go at all), we kept her body alive and suffering for another 3 days. Did we do that for her or because the family wanted it done through misguided perceptions of what medicine should be, family guilt, selfishness or what? Did that family really have the best interests of that woman at heart? Is it the right thing to continue to keep someone alive and in pain when you know they will die anyway?

Sometimes doing no harm means doing nothing and letting nature take its course.

[Rikao4]

in the bushes ,
you must decide..who will be alive at the end of evac.

Rika

[Pazuzu]

Originally Posted by Nathans_Dad

I think you will get quite a bit of the way towards understanding medical ethics when you stop looking at death as a defeat.

I did not say death was defeat, I said this was defeat:

Did we do that for her or because the family wanted it done through misguided perceptions of what medicine should be, family guilt, selfishness or what? Did that family really have the best interests of that woman at heart? Is it the right thing to continue to keep someone alive and in pain when you know they will die anyway?

The fact that you had to take actions that you felt were wrong and inappropriate. THAT was the defeat I was talking about.

I still know nothing about medical ethics. Noah thinks that until the public understand better that things won't change, but he doesn't then give any information to move that process along.

Yes, I've (apparently) completely sidetracked this thread, I'm sorry about that. Either we can move it to a new thread, or you doctors can tell me to piss off since I'm asking something that is not forthcoming.

[Nathans_Dad]

I still don't understand what your question is. I tried to answer you in my post, maybe rephrase?

If you are asking us to explain medical ethics to you in a post, good luck. There are people who have doctorates in medical ethics. It's pretty complex.

There are no hard and fast rules. Everything is on a case by case basis. One basic principle that comes into play in these sorts of cases is that if someone is suffering from a terminal and irreversible condition, then the physician should have an open and honest discussion with the patient regarding whether advanced life support treatments should be used. I do this all the time since my job is to admit patients to the hospital all day. Often the patient has a living will or advanced directive. Sometimes they don't but after a discussion of their prognosis and what may or may not be gained through the use of life support they decide to forgo those measures.

Honestly age has very little to do with it. The whole principle is what quality of life do they have. There may be a case of an active and healthy 90 year old where everything is done vs a 20 year old who is brain dead from a car accident where life support is withheld.

I don't feel defeated when a patient is subjected to invasive treatment that is not going to change their outcome, I feel sad for the patient. I have had to tell a family once (the case we are discussing in fact) that I felt so strongly that they were actually doing harm to the patient by continuing treatment that I could no longer continue to be the doctor on the case. One of my partners took over the case and the patient died a few days later.

[Noah930]

Originally Posted by Pazuzu

I still know nothing about medical ethics. Noah thinks that until the public understand better that things won't change, but he doesn't then give any information to move that process along.

Well, not to sound pedantic, but I've mentioned this in several posts in the past. I didn't want to rehash it. But, in short, the public has to understand that we can't afford to do everything for everyone. It's not economically feasable. We, as a society, have to be OK with intentionally not treating people because we feel that the financial costs do not justify the end results. We have to come to the begrudging agreement that we're OK with that. Well, maybe not OK with that, but at least acknowledging our financial (if not scientific) limitations. And I think our government (regardless of who's in charge), insurance industry, AMA, etc. do our society a TREMENDOUS disservice by not explaining these facts to people. Instead, we get promises and admonitions to "provide universal coverage" because it sounds good and that's what people want to hear. So here I am, at least, doing my bit to educate people one Pelican at a time that WE CAN'T AFFORD UNIVERSAL COVERAGE FOR EVERYTHING AND EVERYBODY. Once society grasps that concept, perhaps we can start meaningful discussions on what gets covered, and what doesn't. Look at Rika's comment; some people get saved, and some don't.