Tuesday, November 11, 2008

Tough Questions About Death & Dying

By Shawn Vuong

In Dr. Holm's latest post, "When Should the Heart Stop Beating," some interesting questions are brought up.
  1. When is a patient too old or too sick to receive expensive procedures?
  2. How can we pay for expensive healthcare for so many people?
  3. If we take away the "easier death" of an abnormal heart rhythm, how will people die?
These are extremely difficult questions, that I do not think many people are ready to discuss. But these are important topics for families, and are a hot topic in medicine. 

One factoid that has been cruising around the medical blogosphere for quite sometime now, is that 5% of our population spends approximately 50% of our healthcare dollars.  How can this be?  Some believe it is all of the expensive treatment we utilize at the end of life.  This time is a very difficult for the family, they may want everything done for their loved ones, when its obvious to the clinical team that there is just not much more anyone can do.  But more often then not, the clinical picture is in a "gray area."  How does a doctor decide that the act of performing surgery or giving the treatment may be worse for the patient than the benefits gained?  The Happy Hosptalist sums up the cost effectiveness of this problem quite nicely.   

How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:

Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site [sic] of the big picture and do things to patients because they can. Because they lose sight of the big picture.  And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.
As a patient and a family member, you may be thinking "Why do these costs even matter? We want everything done for me (or my family member) because that's the right thing to do."  Researchers at Dartmouth argue that more interventions and aggressive treatment do not necessarily prolong patient's lives, and by doing less you may be "sparing patients the agony of unnecessary tests and reducing the risk of hospital borne infections."

The end-of-life decisions are not decisions for cost-effectiveness, insurance companies, or even doctors to make.  The patient and their family ultimately have to decide what is the best route for them. But I hope families realize, they can let their loved ones pass away with peace and dignity without demanding every possible intervention. 

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