tag:blogger.com,1999:blog-2760353953251845523.post8574473754736039978..comments2024-02-10T02:14:39.898-05:00Comments on Buckeye Surgeon: The meaning of lifeJeffrey Parks MD FACShttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comBlogger45125tag:blogger.com,1999:blog-2760353953251845523.post-61363687792473291882012-02-13T21:44:16.641-05:002012-02-13T21:44:16.641-05:00Great post, I've always pondered in what's...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.Edmleehttps://www.blogger.com/profile/12408225117047402607noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-36469795487819534132009-09-05T17:02:00.609-04:002009-09-05T17:02:00.609-04:00Extremely interesting and heart-warming post...I w...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.LJTradcathttps://www.blogger.com/profile/09618988827377725175noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-61258427891608529492009-09-01T17:39:52.320-04:002009-09-01T17:39:52.320-04:00Coming way late to the party but I want to say I l...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.terri chttps://www.blogger.com/profile/09398808840234914275noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-17639104113692419182009-08-12T04:19:48.187-04:002009-08-12T04:19:48.187-04:00I'm late to the party, but I hope some of you ...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.<br /><br />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.<br /><br />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? <br /><br />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. <br /><br />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. <br /><br />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. <br /><br />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. <br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-13997342357342465812009-07-30T05:49:46.175-04:002009-07-30T05:49:46.175-04:00Beautiful posts by Buckeye (and Bongi's at his...Beautiful posts by Buckeye (and Bongi's at his site also regarding the bad living through anything but the good not surviving).<br /><br />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. <br /><br />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.<br />ChelseaAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-2214194607613008752009-07-29T19:25:57.331-04:002009-07-29T19:25:57.331-04:00I hope that just because I'm on a ventilator 2...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."<br /><br />As a patient, Happy scares me shitless sometimes. I don't want the attitudes in medicine to become something like this: <a href="http://www.theonion.com/content/video/gymnast_shawn_johnson_put_to" rel="nofollow">The Onion | Gymnast Shawn Johnson Put To Sleep After Breaking Leg</a>.<br /><br />NickNick Dupreehttp://nickscrusade.orgnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-58304631912085082562009-07-29T13:25:07.398-04:002009-07-29T13:25:07.398-04:00Interesting posts and thread. I've recommende...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. <br /><br />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. <br /><br />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.<br /><br />-Wolverine Palliative Medicine InternistAlex Smithhttp://www.geripal.orgnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-53775292984831824382009-07-29T10:01:48.698-04:002009-07-29T10:01:48.698-04:00Thank you for this. I have immensely enjoyed your...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-66186443080906922802009-07-29T09:53:01.305-04:002009-07-29T09:53:01.305-04:00Thank you for this. I have immensely enjoyed your...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-7804532328447668132009-07-29T09:22:27.224-04:002009-07-29T09:22:27.224-04:00Re: Happy Hospitalist
You are still stretching th...Re: Happy Hospitalist<br /><br />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.<br /><br />Frank did have a point. Credit to whom credit is due.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-78493213049433932322009-07-29T09:00:06.658-04:002009-07-29T09:00:06.658-04:00Wow Frank, a substantive comment from you! There&...Wow Frank, a substantive comment from you! There's hope for you yet....Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-57278747233333738982009-07-29T07:31:43.566-04:002009-07-29T07:31:43.566-04:00Happy,
If we're gonna throw anecdotes aro...Happy,<br /> 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...<br /><br />Yeah, Ronald Reagan was a tough guy...Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-9223603195656358712009-07-28T21:12:16.877-04:002009-07-28T21:12:16.877-04:00Buckeye. I am an advocate of honesty and decency.
...Buckeye. I am an advocate of honesty and decency.<br /><br />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.<br /><br />Then the port developed a thrombus and had to be removed. And this was supposed to be a simple procedure.<br /><br />The the oncologist decided maybe he could treat the tumor with pills.<br /><br />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.<br /><br />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.The Happy Hospitalisthttps://www.blogger.com/profile/14392872203166584371noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-58525263271861490412009-07-28T20:46:46.143-04:002009-07-28T20:46:46.143-04:00Thanks for all the insightful comments. No doubt ...Thanks for all the insightful comments. No doubt this case falls into that category of "moral quandary". <br /><br />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. <br /><br />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. <br /><br />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....<br /><br />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.Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-17002787387331976072009-07-28T18:21:45.583-04:002009-07-28T18:21:45.583-04:00Celeste,
Exactly!
And, why HappyHo thinks he ne...Celeste,<br /><br />Exactly! <br /><br />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. <br /><br />I wonder what is behind all of this. Control issues?<br /><br />-SCNSAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-48882339903064352652009-07-28T13:39:36.493-04:002009-07-28T13:39:36.493-04:00"Healthcare is NOT a right...."
The onl..."Healthcare is NOT a right...."<br /><br />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. <br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-85924025885028406782009-07-28T11:24:15.052-04:002009-07-28T11:24:15.052-04:00Where Happy falls down is by inappropriately extra...Where Happy falls down is by inappropriately extrapolating from palliative chemotherapy to all manner of other interventions: <br /><br /><i>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.</i><br /><br />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.#1 Dinosaurhttps://www.blogger.com/profile/01357845504444464397noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-41293536058221145662009-07-28T10:16:03.638-04:002009-07-28T10:16:03.638-04:00@ Anonymous:
"And I say it isn't her cho...@ Anonymous:<br /><br />"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."<br /><br />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.<br /><br />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.<br /><br />There just has to be more to our humanity than how much somebody says we cost.Celestenoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-39505999845710147242009-07-28T02:14:55.086-04:002009-07-28T02:14:55.086-04:00Dr. Parks honors his patients and himself by givin...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.justmehttps://www.blogger.com/profile/18093595156625216962noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-61004614443045271462009-07-28T00:10:43.580-04:002009-07-28T00:10:43.580-04:00I guess I'm going to be one of the lone voices...I guess I'm going to be one of the lone voices to side with Happy. I think this comment was most telling:<br /><br />"I don't believe the elderly cancer patient has a chance, but it's her decision on whether or not to attempt it."<br /><br />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.<br /><br />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. <br /><br />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.<br /><br />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. <br /><br />This is both good medicine and good public policy.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-71706799967713559802009-07-27T17:24:07.309-04:002009-07-27T17:24:07.309-04:00Does anyone know Happy Hospitalist's real name...Does anyone know Happy Hospitalist's real name?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-87454074898073426422009-07-27T16:29:45.270-04:002009-07-27T16:29:45.270-04:00Great posting.
I think you are a right on the mone...Great posting.<br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-21114540042048671342009-07-27T16:25:51.129-04:002009-07-27T16:25:51.129-04:00You won't find empathy in the writings of Happ...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. <br /><br />Honestly, I hope this lady does well for herself, but also as a big 'ol double-bird to Happy. :-)Nurse Khttps://www.blogger.com/profile/06408755992926959084noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-26839028933112133532009-07-27T14:08:40.994-04:002009-07-27T14:08:40.994-04:00The reality is that these types of decisions on wh...The reality is that these types of decisions on what is it 'worth' are already happening. <br /><br />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. <br /><br />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. <br /><br />Unless you have unlimited resources you must always ask this question.<br /><br />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. <br /><br />There's a worthwhile piece at the New York Times that discusses the concept and I think articulates the debate started here pretty well. <br /><br />http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.htmlAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-69961115808725982642009-07-27T13:52:54.424-04:002009-07-27T13:52:54.424-04:00I'm with Buckeye on this one. I don't bel...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.<br /><br />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.<br /><br />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.<br /><br />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.Celestenoreply@blogger.com