Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, July 06, 2009

Half of the Story

Today's Philadelphia Inquirer has a front-page discussion about expensive surgical interventions in the very aged. They find a few examples of unusually vigorous geriatric patients (including the world-renown cardiac surgeon Michael DeBakey himself, who had an aortic repair at age 97 and lived productively for another two years) and indulge in the usual extrapolation of costs multiplied by the numbers of aging baby boomers. Once again, they get half the story right.

Pennsylvania Hospital's chief of cardiothoracic surgery, Charles Bridges, is correctly quoted thusly:
You have to get out of the idea that there's a threshold age where we think about this surgery differently. With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?
This is an accurate statement of the clinical reasoning required in these scenarios. I agree that there is no arbitrary age threshold above which any given medical intervention should be withheld. Treatment needs to be individualized based on the clinical condition of the patient.

The actual problem is that people in really crappy condition undergo all kinds of heroic interventions all the time, because they're "so young!" Or because some hotshot surgeon thinks he can pull them through, because, yanno, his skills are so extraordinary they can overcome the effect of years of diabetes, smoking and inactivity. (Hint: no, they can't.) Or because the family feels so guilty about neglecting poor demented granny in the nursing home that when she becomes septic and her kidneys fail, of course she need dialysis! You can't let her die!!

There's another great line further on in the article:
[We] are all suffering from a terminal, sexually transmitted disease called life.
So true, yet so difficult for Americans to accept.

A better way to address the issue of health care rationing (yes, I said the r-word) is to base treatment decisions on the patient's clinical condition. Things like whether or not they are still working (like my 81-year-old father), their mental status (why are we performing elective procedures on patients with advanced dementia?), and their co-morbidities (there's a huge difference between the active 85-year-old on only 1 or 2 meds -- yes, they exist -- and the bloated, diabetic, smoking couch potato in his 60s).

A cost-effective, medically appropriate way to address this issue is to curb overtreatment in those patients with advanced dementia and multiple co-morbidites, whatever their age. They are the ones who make all this expensive technology respectively futile and dangerous. Both patients and doctors need to get over the mentality that just because something can be done, it ought to be done. This includes eliminating so-called "screening" tests like annual echocardiograms and stress tests for anyone who's ever seen a cardiologist. It means not starting kidney dialysis in the face of advanced dementia. Perhaps it even means not transferring septic nursing home patients to hospitals in the first place.

We shouldn't be arguing about operating on healthy 90-year-olds. It's the frail, fragile folk in their 70's and younger, bodies wrecked by years of abuse, who ought never to see the inside of an OR in the first place, but who all too often are whisked there without a second thought. We need to start telling the other half of the story.


At Wed Jul 08, 03:06:00 PM, Anonymous Gingerb said...

So my 87 y/o MIL has had a couple of strokes on on her way down she ends up in a wheelchair. She is fading fast.

She ends up with pressure sores and a messed up heel where her foot, which wasn't properly secured in a footrest has been dragged against the floor.

It's ugly. It looks like it hurts but I don't know because she really can't talk too well.

Do we treat that? Does she see a Plastic Surgeon and get admitted to the hospital for debreidment? Given her state you know it's not going to be an in-and-out procedures.

Does she make repeated trips for follow-on care? Do we fuss around with antibotics and dressings?

I'll be a spoiler and say that yes we did. It was futile. She died about the same time the heel was healed up.

I just couldn't see leaving that uncared for. We knew it wasn't going to save her life, but it seemed not right to just let her foot fester.

If we'd left that foot a rotting smelling mess how could we then expect her caregivers to bother to feed or change her? Although she was on Medicare she wasn't on public assistance and we didn't begrudge paying for her care.

I guess I feel like those decisions might sometimes reflect our respect for those we love.

At Wed Jul 08, 03:56:00 PM, Blogger #1 Dinosaur said...

Ginger: There's a big difference between wound care and major invasive procedures like heart valve replacement. I don't begrudge your MIL appropriate treatment, but I hope you'd agree that isn't really what I was talking about.

At Sat Jul 11, 01:41:00 AM, Anonymous totalfailure said...

i want to live!!!!

yes, i am inactive, full of sugar, and smoke like a fiend. but i want to live. i produce, i am needed by the people around me, and my family wants me around.

the current thoughts out there in the world is, you smoke, you drink, you did this to yourself. therefore, no treatment for you. i can see it now; me and another pt are on our tables. i need heart surgery, so does he. he's a life-long welfare recipient with a criminal past. but he's think and doesn't smoke. i am fat and smoke. time to ration...

so now my major motivation for losing weight and quitting coffin nails is not only quality of life, the money, or my desire to score hot chicks, it's simply to be treated when i get sick.

At Mon Jul 13, 05:26:00 PM, Anonymous hashmd said...

Dear Total,

That is fine and dandy to request all the interventions you desire. The problem coming up is that who is going to pay for it all.

Are you personally going to do so? Eventually, you won't because you will be on Medicare and/or Medicaid. Then all the rest of us and my children will be contributing to do so.

That is the rub. Spending the vast majority for care in the final year of life. So your family wants you around. Thats good if they are willing to contribute more for that care.

Many families are not willing to pay, yet demand that care be delivered.

Ultimately the United States will not have enough money to pay for all the care that everyone wants. As the population ages, the US mint could not even print money fast enough given how fast we spend it in healthcare.

There has to rationing of some kind. If it is spent on the elderly, then the children will have to go without.

Dino is NOT advocating that we have an age cutoff. She is advocating that the discussion must be between patient and doctor and risks vs. benefits must come into play.

Is spending $1 million to get one more week of life worth it? At the cost of increased pain and suffering of the patient? (like radiation and chemo in a stage 4 lung cancer patient?) These are the questions that need answering.

At Wed Jul 15, 07:14:00 PM, Blogger Becca said...

Dear Dino

What scares me is this: what about we younger folk with multiple, severe life-long disabilities? I'm 23, I can't weightbear, sit or transfer independantly, I'm dysphagic and incontinent, PEG tubed and catheterised. The hours of skilled care I require run into the low hundreds per week (mostly delivered by trained laypeople rather than nurses). Suction as 'rescue' therapy is on the horizon. I know that night biPAP isn't all that far behind it.

I'm also rather busy living - making friends, playing Guitar Hero (badly!), trying to find the energy to return to university and finish my degree.

No intervention in the world is going to reverse my condition and it continues to progress in the face of plenty of hard work from myself and assorted professionals.

Does that, in your eyes, make me an unsuitable recepient of a heart valve repair? How about skin grafts for a burn? Organ transplant?

It's a bit scary, this rationing business.

At Wed Jul 15, 07:43:00 PM, Blogger #1 Dinosaur said...

Becca: As long as you are "rather busy living", then no, of course my comments don't apply to you. Despite the stance of some of the commenters, I am not discussing the withholding of appropriate comfort care regardless of mental status and prognosis (Gingerb) nor am I addressing the issue of what Totalfailure terms "self-inflicted" conditions. (For the record, I disagree with that designation, as virtually all "lifestyle induced conditions" include a hefty genetic component.)

I am talking about aggressive, painful, expensive care for people with advanced dementia combined with other medical conditions that indicate they are at the end of their life. Believe me, the money spent on interventions in those situations is orders of magnitude greater than what would be required to provide comprehensive lifetime care for all your complex medical issues.

For the record: I am not talking about you. I wish you a long, happy, healthy life (whatever your limitations). All I'm really saying is that end-of-life care in this country is rife with overtreatment, and is an issue that deserves to be seriously addressed.

At Fri Jul 24, 05:25:00 PM, Anonymous Janelle said...

I agree, it all depends on the individual's situation. My grandmother had her second mastectomy at age 80 (first was around age 40). She had her second pacemaker installed at age 85 or something (the first was over 10 years old and ready to replace). She had a DNR ever since her first was put in (didn't want people pounding on her chest). She was always able to beat me at scrabble, and walked miles a day until she was 90 or so...

In the last few months of her life, when we knew things were really going downhill, there were things that we as her family could have done to prolong her life, but instead did our best to keep her comfortable, reasonably happy, and knowing she was loved.

Choosing the right time, the right circumstances, and the right interventions can be challenging, but can ultimately give a person many more happy years to live.


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