Mt Whitney Zone Forums The Chat Room No code -- How Doctors Die

In 2009, Obama's healthcare proposal required health insurance to pay for a doctor to discuss end-of-life options with patients. This could have helped save hundreds of thousands of dollars for each patient who opted out of the pointless treatments Ken described in his article. The Republicans/religious right/pro-lifers killed it by claiming that government "death panels" would decide who would and who would not get care.

In the Terri Schiavo case, the Florida legislature, the Governor of Florida, Republicans in Congress, and President George W Bush all worked to keep a brain-dead woman on life support for seven years. She would still be on life support if they had their way. A Wikipedia article concluded with "Various organizations and protesters demanded that Schiavo's feeding tube be reinserted. Most of these groups were affiliated with the Christian right."

I conclude that the Christian right is contributing to the problem you describe.

yes, those are certainly high-profile cases, but not what we usually see "down in the trenches" where common sense prevails in the absence of governmental-intrusion.

I happen to agree with you on many aspects of this discussion. Just as an example, let's look at the history of End Stage Renal Disease (ESRD). From Wikipedia, with my underlings:

"In 1972 the US Congress passed legislation authorizing the End Stage Renal Disease (ESRD) program under Medicare. Section 299I of Public Law 92-603, passed by Congress on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease (CKD) and were otherwise qualified under Medicare's work history requirements. The program's launch was July 1, 1973. Previously only those over 65 could qualify for Medicare benefits. This entitlement is nearly universal covering over 90% of all US citizens with severe CKD."

So there you have it. Entitlement. Known otherwise as OPIUM or OPM - other peoples money.

Before that, at my institution, there was a diversely-made up "panel" to see if it was the right thing to do (for those patients considering using the improving field of dialysis and transplant) from a personal, social, economic, medical and other perspective. After that, the government had basically decreed that no one should die of kidney failure even if they were hopeless, useless, nursing-home bound, brain-damaged, prisoners, etc. The pendulum had swung way too far over those years and seemingly is now swinging the other way. So rather than using a sound-bite to call the proposed decision-making panels "death" squads, maybe they should be called "common sense" squads. On the other hand, are such panels needed, versus, say just the discussion between patient/family/physician? But the scenario is more difficult when there is no family, or the patient is unable to understand or communicate for a variety of reasons from medical to language barriers, intelligence, etc. Who gets to decide? The bean counters? At some point the answer is yes, they need to be involved as well. How much is a life worth? A former useful life worth? A no-hope life worth? An illegal alien life worth? A drug-crazed high school dropout life worth? A 90 yr old nursing home resident with hip fracture? And so forth.

This is a Gordian Knot.

Thanks everyone, for this discussion, beginning with Ken's post.

Bob, in that sense, I agree with you.

I also agree with Harvey, though, that for the most part, that doesn't affect us in the trenches.

Doctors don't get paid to have discussions on end-of-life issues. Does that translate into those discussions not happening? No. They happen.

In my 28 years of practice, and hundreds of terminal cases, I can vaguely remember a couple in which a religious advisor of any sort was involved in any decisions...and generally, they were helpful with the family coming to grips with the reality of the situation, because they, like us, had been down this road before. I wish there'd been more.

In my writing, I have been exceedingly careful not to characterize anything in a way that would be seen as tilting in one direction or the other politically. I know that if I do, I will be attacked by the other side. That's the political game, which is played for high stakes.

The article states the broad-spectrum dilemma/promblem, exquisitely. The end of life decisions/issues in my experience, level the field, rendering the participants emotionally incapable of applying higher order reason/philosophy/psychology/liturgy (most of the decisions are far more subtle than "to plug or unplug", rather its a 30sec moment of to apply CPR, insert the lung tube or a 24hr decision for another "procedure"). Its raw.

Bob - I think you make an excellent (and might I say obvious) point there are groups which work hard to shape public policy, and health care review panels is no exception. That they don't typically get involved in specific cases - except high visibility ones like Terri Schiavo - doesn't mean they are not working hard to support their point of view.

Other countries, notably in Europe, have come to the realization that resources are finite, and attempt to put in place those processes which distribute those resources. We (the U.S.) operate as though resources and growth are infinite. Not much will change until/unless we can accept that there are limits.

Time Magazine, now.

Article here

You're going to have to write a book, Ken!

Here's the Time link:

Shannon Brownlee on What Doctors Know — and We Can Learn — About Dying | TIME Ideas | TIME.com

A good quote from that article, with a link to "POLST" physician forms that people can fill out:
"Some of the most informative forms can be found at Physician Orders for Life Sustaining Treatment Paradigm."

Funny you should say that, Steve. I was contacted by a literary agent from a major publishing house last week to do exactly that. He specializes in working in developing an article into a book. One of his last authors was Siddhartha Mukherjee, who wrote The Emperor of All Maladies: A Biography of Cancer.

Amazing book, strongly recommended.

It won the Pulitzer Prize, so he must know what he's doing.

Could I get an autographed copy of your first edition?

I second the recommondation, Ken -- the book was awesome. Check out the interview with Terri Gross, too; the author is a humble, elegant man.

I've met Sid, and you describe him perfectly.

Steve, you'll have it.

an adaptation I'd written of my original article appeared in the Wall Steet Journal Saturday.

Why Doctors Die Differently

As of this evening, it is the 2nd most read article by readers, and the most emailed. Quite something to see it on the front page Sat morning.

Amazing. I am astonished by the "legs" of this. It was published in the Guardian in england a week ago, and I was interviewed on Irish Public Radio (after the Farming Report with Mairead Lavery)

IPR @ 7:58

Australian Public Radio next week.......

"... Physicians really try to honor their patients' wishes, but when patients ask "What would you do?," we often avoid answering. We don't want to impose our views on the vulnerable."

Personally, I don't let a doctor "off the hook" by sidestepping the question. And I would not create a long-term relationship with a physician unless I felt he/she would give me their own view on such difficult matters. After all, they deal with these issues frequently, and if they withhold their opinion on this, then my emotional response would be - "OK, what else are they withholding", and my trust in their judgement is gone.

You touched a nerve. I'm glad that the WSJ picked this up. Ken, thank you for the clear and well expressed thoughts.

Brent N

That's ok, Kevin. I think we generally won't let you off the hook of making a decision.

First, not everything is black and white, but sometimes shaded with grey, and it may not be so easy to know what one would do...particularly when the decision might be very laden with what a person's philosophy would be.

Second, you've never experienced expressing your opinion, then having a very angry family come at you with a complaint that you were..... 1. trying to kill granny, or 2. trying to keep her alive so you could fleece more money out of her....by forcing your philosophy upon her. These are often accompanied by a threat of a lawsuit, which really enhances the situation.

Third, you've not been fired from a case because what you expressed in your opinion... which was not what you thought should be done, but was only what you would do, yourself....makes the patient feel uncomfortable that you will carry out their wishes, that are different than the opinion you'd expressed.

Resuscitating this (pun intended, of course)

Ken is a participant in this Raidolab.org interview. Radiolab interviews play on Public Radio stations, and is also supported in part by the National Science Foundation.

    The Bitter End (a 21-minute dialog)

Oh, wow -- I listen to this program every week (@9am fri) This must be tomorrow's program!