Monday, December 22, 2008

Is This Appropriate Health Care? You Decide.

A 97 year old woman, while in an intensive care unit in a smaller community hospital had written, “Please let me die." Later after transfer to a larger hospital she was on life support and slowly decomposing - literally. This is an example of a modern American tragedy that happens to many thousands yearly.

Because this woman did not have an advanced directive, she was kept “alive” by a reluctant medical community under the authority of a legal guardian and a probate judge. The judge did not seek medical opinion as to the patient’s viability, chances of recovery, damage to her body that would occur as a result of the breathing & feeding tubes, irretrievable lack of consciousness and multi-organ failure. Rather, the judge chose to rule that without a properly executed advanced directive, every conceivable medical treatment must be utilized to keep her heart beating.

Wrapped in legal jargon, most would argue that this was an irrational, cruel and inhumane plan for this 97-year-old person. She had no chance of recovery. Those caring for her felt helpless in the midst of a legal system that is abstract in its reasoning and makes decisions as if medical science does not exist. A well meaning and caring society spends billions of dollars to perpetrate this kind of action upon thousands of dying Americans yearly despite excessive health care costs.

The Patient Self Determination Act passed Nov. 5, 1990, stated that patients have the right to create advanced directives stipulating what they wish done in an end-of-life situation. The act was never intended to mean that those without an advanced directive must undergo care that cannot be of benefit, is disfiguring to their body and draining resources from the rest of society. Quoting from the Philadelphia Inquirer, Nov. 7, 2005, "After three decades of urging Americans to write living wills (they preceded advanced directives), many doctors, lawyers and ethicists concede that these documents have largely failed”. Every case is different and therapy must be individually tailored. Thus it requires knowledge and judgment to treat in an appropriate fashion. This cannot be done in judge's chambers as an abstract exercise in fine points of the law.

The question to be asked is: does this irrationality in medical care apply only to end-of-life situations in American Medicine? Unfortunately, as has been repeatedly documented on this blog and in my book, the answer is a resounding NO! Dialysis, cardiac catheterization with stents, knee surgery, and excessive use of expensive radiological equipment (i.e. proton accelerators) are only a few examples of medical technologies that, when used appropriately, are terrific, but are being overused and thus abused. No wonder there are not adequate funds available to support primary care and universal heath care coverage.

Wednesday, December 10, 2008

The Need for Appropriate Care Committees – A Case Study

The burden of decision making in medicine and especially in end of life situations can be painful. We need to feel confident and supported in these difficult circumstances. No one wants to lose a loved one, yet we all know that life is temporary. We need to be sure that the decision to withdraw temporizing measures is correct. Frequently the family, as the patient advocate, assumes they are fighting for the patient and demands the use of multiple gadgets. The doctors comply although knowing they will be of no value. The family thus assumes that perhaps the doctors believe there is a possibility of cure.We need a system to help guide us through an experience that for many, and reasonably so, is very difficult. Following is a case from my own experience that clearly shows why we need appropriate care committees.

The daughter of a patient in the ICU with no chance of recovery was adamant that we continue care. After we exhausted all possibilities as formulated by the AMA Policy to Discontinue Care Against Family Wishes, care was withdrawn and the patient quickly died. After the funeral the daughter came back to the ICU to thank us. She told us that as long as we were willing to care for her mother maybe we thought she did have a chance to survive. But, by withdrawing care she knew we thought survival was impossible and that took the burden of letting her mother go out of her hands.