Saturday, July 25, 2009

The meaning of life

The Happy Hospitalist took aim at my post from last week on the spry 92 year old lady with metastatic breast cancer who needed a Mediport for her adjuvant chemotherapy. As anyone who reads the Happy Ho would expect, he comes down hard on the decision of myself, the patient, and the oncologist to proceed with aggressive chemotherapy on someone obviously in the twilight of life. He writes:
So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?

Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.

Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.

I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.

A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?

Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.

Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?

This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.

Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."

I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.

Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....

45 comments:

platensimycin said...

Heartfelt and certainly thought-provoking. Excellent post, Buckeye.

Dan said...

It's an inspiring post, no doubt about it.

Random thoughts in reponse: Presumably she is not footing the bill for the treatment? At 92 I'm guessing she isn't covered by an insurance company. She is covered by medicare (and maybe if she's lucky, VA).

Seeing your references to various philosophers made me think of Kant's Categorical Imperative: Does that make sense if you universalize it? In other words, you don't take in to account the particulars of this scenario -- you just always choose to "keep fighting." Does that make sense to you? I'm not sure that it does to me.

On the other hand, Kant would probably say that people choosing to die is not logical either. Thanks Jeff. You're a good man Charlie Brown. :P

Bongi said...

beautiful and eloquent. fortunately i'm not a burocrat in the halls of power making the decisions on how to best spend health money and although i wish i was, i concede i'm not much of a philosopher like you clearly are. all i am is a guy who hopefully can see the humanity in my patients and make a difference on that level.

buckeye, well done in treating the very soul of this patient, even if you did it by just quickly throwing in a portocath.

Robin said...

Very well said. I dislike the thinking in health care that weighs and measures treatment based on factors such as age or economics.

Life is random. You could treat a 40-year-old for the same disease at same cost and that person could be killed in a car accident. That doesn't mean the resources were wasted any more than they were on your 92-year-old.

We're all going to die but the focus of our lives and our health care system should be on providing care and dignity to everyone irrespective of age or economic situation. If we can't find a way to do that we lose a portion of our humanity.

radinc said...

well we pick a number. in all these health care reform scenarios ultimately we have to set the number.

what is a year of life worth?

I guess the standard today is $50,000 but I've seen as high as $100,000.

chemo costs $x, and it buys y months of life. do the math. get the answer. easy.

that's what it's going to come down to right.

later,
radinc

BR Morrissey said...

Another brilliantly written, well thought out piece. It's a pleasure to read your work.

#1 Dinosaur said...

I doff my cap to you, sir. Very well said.

My point about the economics, though, is that far too many people with far less "life" in them undergo way too many aggressive treatments undertaken with far less thought than you have put into this case. If all doctors brought the same consideration to their work as you do, there would be plenty of resources available to those who can benefit from them.

nemsova said...

dr parks, you capture perfectly the instances in our lives in which we function at our highest levels-- these special, infrequent, moments that tie us to the rest of humanity and force us to leave behind the mundane. they are episodes of pure connection, human to human; and the ways in which we choose to respond speak to our humanity and growth. carl rogers' theory of self actualization comes to mind. well written post, dr, thanks

Anonymous said...

Buckeye, and Bongi
Both of you have posts that I read if I need reminding to keep centered in my soul. I think that in this business some people are never able to step out of selfishness and realize that it is all about the patient. These people are lost.
-SCNS

Anonymous said...

How much i wish i could encounter doctors like Buckeye rather than HH if and when my family fell ill! Most of the time the probability (dictation, really) of such encounter is well not in patients' favor, though.

Falling ill [for most of the time] is not of patients' choosing. We/patients are grateful when we are treated as fellow human being (as one local ENT did) even if the prognosis or the outcome were poor, rather than a purse (as another ENT in the same clinic did), an insurance card or a bag of ailment.

Thank you for the inspiring post, Doctor Parks. NK

The Happy Hospitalist said...

That was a nice story. But I have to ask you, if you were a nephrologist, would you offer her indefinite hemodialysis. If she had lung cancer and a solitary brain lesion, would you offer her brain surgery and lung surgery? If you were a transplant surgeon and she had end stage heart failure, would you offer her a heart transplant? If she had 4 vessel coronary artery disease and a bad mitral value, would you offer her bypass and valve repair?

In every case, she's functional. In every case, not doing anything is fatal. Are you saying to me that you feel age plays no part in the offering of interventions to patients?

I would disagree completely. Age is one of many very important aspect of offering medical care to patients. Biology says so.

The nephrologist does not hold a duty to offer dialysis. The transplant surgeon does not have a duty to offer transplant. The neurosurgeon does not have a duty to offer brain surgery. And the CT surgeon does not have a duty to offer bypass.

And everyone of them has a right to base their decision on age and their experience with the outcomes in this age group.

Giving chemo, doing bypass surgery, doing dialysis, what ever on a 92 year old, no matter how functional they are, is not the same as doing it on a 50 year old.

Biology dictates that physicians offer reasonable therapies based on expected outcomes.

I personally, feel offering major interventions of any kind to 92 year olds with fatal disease is unfair to the patient, friends and family, who will lose their loved one to a year of hospital acquired disease, which will in all likelihood kill her quicker than by doing nothing and letting her live peacefully at home.

You may say it's not may decision to make. But as the doctor who is offering major interventions to 92 year olds, it is. I am not just the pawn for the patient's wishes. If the patient does not like my decision to offer nothing, they are free to shop around until they find one that does offer them what they want, should it go against my medical judgement.

By the way, I'm not anonymous. Far from it. Everyone that matters in my life knows exactly what I do. I speak truths often that have upset many that know what I do. I take strong positions because I am passionate about my opinions. What everyone else thinks doesn't matter. I could care less what medic this or RN that thinks about me. In fact I see the filth written about me on other blogs and I know deep down these people are good people. I just choose not to belittle myself in such a way.

The economics of the situation are quite clear to me. We as physicians should stand up for what's right about our profession and give managed expectations to patients who believe what they see on TV. Telling a 92 year old to spend the last 6 months of her life in misery is not my idea of good medical care. And that's my decision to make. Not the patients. And if the patient doesn't like it, they can go else where to get what they think they need.

Anonymous said...

Re: Happy Hospitalist

With your many "if"s - i assume you at least understand that clinical dictation is an individual case-to-case consideration.

"Age is one of many very important aspect of offering medical care to patients. Biology says so."

One of MANY aspects, you've got that right. Citing biology on numerous occasions, you probably should teach biology rather than practice medicine, HH.

"I could care less what medic this or RN that thinks about me."

It's probably because they find your clinical decisions distasteful and wouldn't give you much of their regards.

"And that's my decision to make. Not the patients."

What kind of rat-ass medicine are you practicing? Take a count of how "I/my"s you use here to justify your clinical decision.

Let's bring this fight to your blog.

Frank Drackman said...

Don't wanta "Out" anyone...

But Happy's real name is Dr. Josef Mengele Jr...

Explains alot, except his dad did actually treat some stuff...

Frank

Anonymous said...

Get a life, Frank.

Dr Bethilda said...

Buckeye, I think that your 92 yr old woman should be given the option of chemotherapy, granted that she will probably have poorer outcomes than most. Particularly if she has the marbles to understand her options.

That said, the last few older chemotherapy patients that I have seen had a poor quality of life and died of neutropaenic sepsis.

I remember one 93 yr old man who came in every two or three weeks with angina (due mostly to left main coronary artery disease) He was appropriately not offered a bypass, due to his advanced age. After recurrent presentations, the cardiologists offered to stent his very large artery, on the understanding that if it went pear shaped then he would not be resuscitated. It all went well and he went back to living by himself and looking after himself.

Mind you, I work in Australia, so perhaps things are different, here.

Only last week we did not offer an ICU bed to a mildy demented nursing home patient with Gram negative sepsis. Just lots of fluids and some antibiotics. Fortunately, he got better.

Which begs the question; who decides what treatment the patient gets? Should it be the patient, the family, the treating doctor? Should we have guidelines, or should your friendly (I have your best quality of life issues in mind) insurance company get a say?

steveperry said...

First of all, great post Buckeye.

Secondly,
neither the government, nor any other third party should be able to dictate what treatments are done IF the patient is footing the bill (obviously not likely, but still a possibility, especially in a life-prolonging situation) AND the physician in question is a willing participant.
End of story.

Like you said Happy, you have every right in the world to refuse to treat them, but no one should be able to tell a physician (if they are working for themselves) not to treat them under those circumstances.

Now, when other people are footing the bill through higher taxes and premiums, then you may have a point Happy with regards to the limitations of what physicians can do for what patients, and that should be set by those paying for it (Ex: us the taxpayers). You can't demand someone else pay for your million dollar ICU stay so you can scrape together a few more months.

I just wanted to make that point clear as I feel adamantly about the individual rights of people involved in their own healthcare if they are willing to take complete responsibility for the costs and complications.

Healthcare is NOT a right, but you shouldn't be able to take away someone's ability to "shop around" for another provider if they are willing.

Clinton said...

If you wrote such a beautiful note on the preauthorization form...

you'd get my stamp of approval.

that was a wonderful appeal to what matters most to THIS patient in THESE circumstances.

Rules are rules. Guidelines are guidelines.

And every once and a while, someone exceptional comes along. I agree that they should be treated exceptionally. Not being ageist or "exceptionalist". Simple principles of distributive justice should always be applied on a case-by-case basis and I salute you, Buckeye.

:)

Frank Drackman said...

Clinton,
that might just be the creepiest reply I've ever read except for some of those websites where guys like to dress up like babies...
So what they said in 4th grade about stuff goin on your permanent record is true... If you wanta get your colon cancer treated at age 97...

"Every Once in a while someone Exceptional comes along"

and people wonder how the holocaust happened...

auf wiedesehen,
Frank

lynnpricewrites said...

Your writing is a mug of hot chocolate; it's good for the soul. In sharp contrast, HH scares the shit out of me because I wonder how many other doctors believe as he does. What if I'm going to a doctor who thinks like this? His beliefs would actually bring about my demise much faster, and no one would blink an eye. Is this our Brave New World?

steveperry said...

The scariest part is that he believes what he does, however distasteful it might be. No performance rating can red-flag ones like him.

Celeste said...

I'm with Buckeye on this one. I don't believe the elderly cancer patient has a chance, but it's her decision on whether or not to attempt it. We had this same scenario in our family and our relative didn't last the year on chemo; she got some infection that she couldn't fight and that was that.

Nothing in the current provisions gives the doctor the right to justify it based on cost to the aggregate. I don't think we can say it is "patient abuse" if the person is told the risks and consents to it.

Mostly I wish that hospice didn't have the stigma to it that many people believe--that giving up treatment is giving up on life, and bad. Sometimes treatment is the bad decision and giving up on it is a good thing.

My husband and I talk all the time about how if we got certain cancer diagnoses, it wouldn't be worth it to treat them because of the huge cost you are still stuck with after insurance, combined with lost wages. We both think it would be better to just let it run its course and leave behind assets rather than debts, especially with a child to raise.

Anonymous said...

The reality is that these types of decisions on what is it 'worth' are already happening.

That's what our private insurance companies do today and it's what Medicare is doing today. Our coverage and 'worth' is decided based upon our employers willingness to pay, the insurance companies to perform their actuarial analysis based on this and come up wtih a plan which we (individuals) also pay. So in the end, it is still based on our combined abilities to pay which is a rationing mechanism. Without our abiltiy to pay the premiums (or taxes) to fund the system, we can't pay for treatment, prevention, etc.

I don't mean to write this in a negative way, as I think someone will always have to say how much can we spend and for what benefit.

Unless you have unlimited resources you must always ask this question.

Would you and I be willing to pay $5 more in our premiums to pay for the 92 y.o.? How about $50 or $5,000? At some point we are making this decision whether we like it or not.

There's a worthwhile piece at the New York Times that discusses the concept and I think articulates the debate started here pretty well.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html

Nurse K said...

You won't find empathy in the writings of Happy Hospitalist. Everyone is a billing code, a paycheck, a burden if they're ill, good if they're healthy, good because they exercise or bad because they don't.

Honestly, I hope this lady does well for herself, but also as a big 'ol double-bird to Happy. :-)

Anonymous said...

Great posting.
I think you are a right on the money with this one,and as for the ''HAPPY HOSPITALIST'' his aim missed the target by a long shot.

Anonymous said...

Does anyone know Happy Hospitalist's real name?

Anonymous said...

I guess I'm going to be one of the lone voices to side with Happy. I think this comment was most telling:

"I don't believe the elderly cancer patient has a chance, but it's her decision on whether or not to attempt it."

And I say it isn't her choice. Just as it isn't a patient's choice to get an unnecessary xray or an unnecessary lab test or to get an unnecessary medication.

If the test, treatment, or what ever isn't going to make a real difference, then it shouldn't be done. Sorry. End of story. This is something that we try to drill into the heads of residents, but we can't accept it ourselves. I understand the drive to do something. Sometimes the better part of valor is not to.

The reality is that technology with always get better. There will almost always be something else that we can try. These things come with a cost. The healthcare dollar is limited and will soon be spread even thinner. The only sustainable way to keep it going is to do less. Even the GAO reports that huge cuts in payment won't save enough money. It is time to take the first step.

What is that? Accept that death is not failure. Everyone dies. This is a fact. It is a sad fact, but still reality. There are natural transition points from life to death. Expending huge efforts in both cost and labor to try and prevent what is inevitable denies reality. I'm not taking about leaving your average senior citizen who is septic to die without treatment, but when a person has a fatal condition the focus need to change from beating it at all costs, to making the patient's last days best.

This is both good medicine and good public policy.

justme said...

Dr. Parks honors his patients and himself by giving the cognitive and emotional energy and time to consider each patient as an individual. He 'gets it' that medical care is a personal, intimate human to human interaction instead of a efficient, check all the boxes, and move to the next room kind of job. The fact that he THINKS and CARES is reassuring and the doctors that see only data instead of people are scary.

Celeste said...

@ Anonymous:

"And I say it isn't her choice. Just as it isn't a patient's choice to get an unnecessary xray or an unnecessary lab test or to get an unnecessary medication."

Necessary...who decides that? It seems like it should be a joint decision between the doctor and the patient whose life is most directly affected. The only reason the patient knew her cancer had returned and spread was from scans that were done and found the lesions. I say once you have done the scan and found the results, you have obligated yourself to offer treatment options (including do nothing). If your policy is that you refuse to scan somebody over a certain age because you don't want to treat cancer past a certain age--you should most certainly make that clear so that people can decide if they agree with how you want to treat them.

Regarding the necessity of trying medical treatments, I do believe that for many people, the attempt does help them accept reality. I have personally known of cancer patients who chose to stop treatment after not getting initial good results, and I also know of people who needed to attempt fertility treatments to be able to accept adoption as a viable choice for themselves.

There just has to be more to our humanity than how much somebody says we cost.

#1 Dinosaur said...

Where Happy falls down is by inappropriately extrapolating from palliative chemotherapy to all manner of other interventions:

The nephrologist does not hold a duty to offer dialysis. The transplant surgeon does not have a duty to offer transplant. The neurosurgeon does not have a duty to offer brain surgery. And the CT surgeon does not have a duty to offer bypass.

It's like saying, "Well, if you're not going to run a marathon, why bother running, or walking, or doing any kind of exercise in the first place?" No one is claiming that a functional 92-year-old should be offered dialysis, transplantation or cardiac bypass, even if she requested it. Happy is over-generalizing into absurdity.

Anonymous said...

"Healthcare is NOT a right...."

The only place where access to reasonable health care is not a right is in the wild, where you get hurt, maimed and then [slowly or violently] die. Force of nature. In civic society, even those behind bar (and, for Pete's sake, even animals in local zoo!) seem to have "right" to access reasonable health care.

The society's ability to provide aid and reasonable health care to those that are injured or ill is what defines and perhaps separates civilization from Old Wild West.

Anonymous said...

Celeste,

Exactly!

And, why HappyHo thinks he needs to play "Secret Squirrel" with information, IDK. I would hope that HappyHo would FULLY present all options available, and then respectfully advise patient/family of his professional recommendations as well as intentions in further care involvement, if they do choose an option he feels he cannot participate in. Leave the door open... I don't get the feeling that it works quite like this with him.

I wonder what is behind all of this. Control issues?

-SCNS

Buckeye Surgeon said...

Thanks for all the insightful comments. No doubt this case falls into that category of "moral quandary".

I think the important thing to take home is that end of life decisions are not made solely by a paternalistic doctor. There is no "elderly abuse" here. These conversations with the terminally ill are awkward, painful, raw, and brutally honest. And they need to happen more often in our profession.

All we can do is offer patients the best palliative options that are available, in the context of all the side effects and quality of life issues that can arise from said intervention.

Happy is obviously a strong advocate for some sort of Abstract Social Justice principle, and that's fine. But even the most logically coherent socioethical philosophy tends to go to pieces when find you struggle to fit the square pegs of actual humanity into the perfect round holes of pure theory....

These are the kinds of discussions we need to have though. It's bad medicine to overtreat the terminally ill without informing them of the consequences and involving them intimately in the decision process. But it's equally bad to write them off, turning away just because they happen to exceed some arbitrary age limit. Somewhere in between these two paradigms is where true justice resides.

The Happy Hospitalist said...

Buckeye. I am an advocate of honesty and decency.

By the way, just yesterday a colleague of mine told me about their relative, who was just diagnosed with breast cancer, not even metastatic mind you. They got a port. Putting the port in caused a pneumothorax. The pneumothorax required a chest tube. Then it required a second chest tube. It came with terrible pain.

Then the port developed a thrombus and had to be removed. And this was supposed to be a simple procedure.

The the oncologist decided maybe he could treat the tumor with pills.

Placing a port, a presumably very simple procedure can be riddled with complications. Complications, which in the grand scheme of treatment, could lead to a death much quicker than the natural progression of the disease itself.

Accepting mortality and dignity with death are issues physicians owe to their patients. They do not owe them every possible technology known to man, especially in therapies of unproven benefit.

Frank Drackman said...

Happy,
If we're gonna throw anecdotes around, I knew a 74 year old with Colon Cancer, had a hemicolectomy. Few years later, got Prostate Cancer, got that treated. Also had some basal cell carcinomas whacked off his face. Then at 80 he fell off a horse, got a chronic subdural,don't have to tell you how much that cost to fix... Few years later got Alzheimers and died...

Yeah, Ronald Reagan was a tough guy...

Buckeye Surgeon said...

Wow Frank, a substantive comment from you! There's hope for you yet....

Anonymous said...

Re: Happy Hospitalist

You are still stretching the point. Pneumothorax is a foreseeable - and rare, if i mind you - complication of port placement. Keep dodging the point and pulling tangent anecdotes,HH. They speak volume.

Frank did have a point. Credit to whom credit is due.

Anonymous said...

Thank you for this. I have immensely enjoyed your thoughts, and applaud your reasons for wanting to treat your patient. Best of luck to you, and to her.

Anonymous said...

Thank you for this. I have immensely enjoyed your thoughts, and applaud your reasons for wanting to treat your patient. Best of luck to you, and to her.

Alex Smith said...

Interesting posts and thread. I've recommended it for palliative care grand rounds next month (a review of blogs that touch on palliative issues). Completely agree that basing treatment options on age criteria alone is nuts. The analogy that comes to mind is cancer screening in the elderly, something Louise Walter has written eloquently about (see Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750-2756). The one-size-fits-all approach does not work for cancer screening in the elderly, and it does not work for decisions about chemotherapy administration.

What is important in both cases is that the physician engage the patient in a careful discussion of the patients goals and values and how they relate to the treatment (or screening decision) at hand, in the context of the patients health status. Doctors also need to convey to patients some information about prognosis, and this is often the hard part. Buckeye decided to go forward with surgery in this case in part based on the robust appearance of this elderly woman. That was a prognostic decision. Had the patient appeared ill and near death, he presumably would have recommended otherwise.

These discussions take not just care but skill, and as Buckeye noted, are "awkward, painful, hard, raw, and brutally honest". One of the take home messages for me from this anecdote is further evidence that physicians need high quality training in how to have these difficult conversations with patients and family members.

-Wolverine Palliative Medicine Internist

Nick Dupree said...

I hope that just because I'm on a ventilator 24/7 (and have been for 14 years) that a doctor doesn't declare my quality of life not worth saving, and only the non-disabled should use "limited health care resources."

As a patient, Happy scares me shitless sometimes. I don't want the attitudes in medicine to become something like this: The Onion | Gymnast Shawn Johnson Put To Sleep After Breaking Leg.

Nick

Anonymous said...

Beautiful posts by Buckeye (and Bongi's at his site also regarding the bad living through anything but the good not surviving).

HH - you are not being honest and decent when you unilaterally decide to withold information and full discussion from the patient. Whether one calls it paternalistic or God-like or whatever.

Uniformed, or partially or mis-informed patients wouldn't necessarily know to seek out another provider if the options, along with risks, are not discussed in the first place. Granted, this isn't going to always be in the interest of health care reform, or guarantee that you'd get through to the patient the true magnitude of some of the risks. The duty lies not so much in the treatment you're willing to offer, but in a full dicussion of at least standard options under more ideal situations regardless of age or income or ability to pay. You're more than welcome to state why you don't think something is reasonable, but you should bring it up first. Share your knowledge and experience in such intimate situations. Aide in the cause of educating patients and their families on an individual level. Perhaps you should've gone to law or engineering school instead. There's some connection synapse missing.
Chelsea

Anonymous said...

I'm late to the party, but I hope some of you find my addition constructive and non-repetitive. It seems that, to some degree, that HH and Buckeyewere were talking past each other, i.e. about different issues.

A couple of the comments have hit on this point, but I thought I would elaborate the opinion espoused by those like DrRich: we already ration medical care today. It may not "feel" like it, but employers are not actually eating the extra cost by pulling money off of each trees. These increasing costs are deducted from employee wages and/or priced into the product/services provided by the company.

So long as we pay for medical expenditures from a common pool of money (no matter what the system) the members who contribute to this pool are paying for the care of the 92-year old. In the case of the US, we just push the costs to future generations. By treating the 92-year old you are quite literally taking money away from future generations because you cannot just keep on borrowing money forever. Isn't that what the whole credit crisis is about?

So, the decision to treat the 92-year old isn't as free as you think. When you frame it as HH did, it does seem cruel to deny care to a 92-year old patient, but I think what HH is really trying to say is that this money isn't free. When you pay for the 92-year old to get the procedure there is an opportunity cost associated with that money. It isn't coming from nowhere.

That doesn't mean the decision in this case is wrong, nor does it mean it is right. What it means is that it is a legitimate PUBLIC HEALTH issue. The story was framed in a vacuum as if treating the 92-year old wouldn't take away from some other good, but every decision has an opportunity cost.

I'm not a fancy economist here, nor am I an ethicist or even a doctor. I'm just a pre-med student here trying to make sense of the hysteria on healthcare reform. And, frankly, I'm thoroughly confused on what is the right thing to do or how we solve this societal problem.

The idea of government coming up with "guidelines" or "rules" scares the heck out of me...and based on a few posts (admittedly I'm new to your blogs) I'm fairly sure HH is against that too. Moreover, on other posts I saw Buckeye did concede the point that rising healthcare costs are unsustainable.

So I think there's some common ground here...the disconnect is whether or not we recognize that healthcare is already being rationed, and once we admit that then we can discuss -- hopefully without hysteria and name-calling -- how best to ration healthcare.

terri c said...

Coming way late to the party but I want to say I like this post very much and some of the comments are thought-provoking too. It may be that, if people were able and willing to make their feelings about end-of-life care clear to those who might have to act for them, it would be easier to know who really DOESN'T want that chemo/ventilator/pressors and who does, and that alone might bring about some savings.

Cynewyn said...

Extremely interesting and heart-warming post...I wish there were more doctors like you, in the job through a desire to help cure the sick and suffering, and not about economics and deciding who should live or die.

Edmlee said...

Great post, I've always pondered in what's really in life after my mother passed away due to cancer. Right now I feel like I'm just another animal living in this very random world not knowing what's going to happen tomorrow, but just trying to do what I can to help more people (giving blood/etc). Of course, it's at a much smaller scale of the work you do and lives you save. Great insight and very heartfelt blog.