Friday, January 16, 2009

Why we Need Appropriate Care Committees: A Case Study

Linda Jones was an 87 year old woman who had been in a nursing home for the past four years. She was admitted to the nursing home by her two daughters because of mental deterioration to the point of being unable to care for her self. Since entering the nursing home she had been transferred to the hospital six times. The first, three years ago, was for pneumonia and while in the hospital her daughters agreed to the placement of a feeding tube. However, her daughters were concerned about her over all well being as she did not recognize them and could not communicate in any meaningful way. She appeared to be unaware of her surroundings and did not respond to her name. Her third child, a son, lived thousands of miles away and was not in contact with his mother or sisters. Linda was returned to the nursing home which was now reimbursed at the much higher Medicare rather than the Medicaid rate. During the past three years Linda was readmitted to the hospital five times, twice for pneumonia and twice for urinary tract infection, each time bumping up the nursing home collections from Medicaid to Medicare. Her last admission to the hospital was for sepsis (bacteria in the blood) possibly from her lungs, urinary tract or the small skin breakdown over her sacrum that the nursing home tried diligently to prevent. In the hospital Linda was placed in the intensive care unit (ICU), intubated (breathing tube) and given other medications.

The ICU doctors told her daughters that Linda was terminal. Her daughters agreed with the doctors that she should not under go cardiopulmonary resuscitation (CPR) and should be transferred to hospice, but wanted to wait for their brother who was about to arrive. Linda, like most Americans, had not executed an advance directive nor designated a durable power of attorney. The son arrived and strongly disagreed with the do not resuscitate order and hospice despite meetings with the ethics committee which had agreed with the ICU doctors. The hospital having had unpleasant and expensive legal experiences in such circumstances took no action. Linda remained in the ICU for another three weeks, had a cardiac arrest and died after one hour of attempted CPR. No autopsy was performed.

Linda’s ordeal is reproduced in one form or another hundreds of thousands of times in American hospitals yearly. The results are: 1) Linda suffered a disfiguring intrusive death that was an assault on her human dignity. 2) The family as a whole (all three children) was faced with decisions they were not prepared to make and were mired in conflict. 3) Doctors and hospitals have become accustomed to, and in many cases financially dependent on, providing non-beneficial care. 4) The resources consumed were enormous.

What would have happened if my admitting form and appropriate care committee system were in place? Upon Linda’s first hospital admission the admitting form would have created a contract between Linda, her family, and the physicians which stated that only beneficial care could be delivered and also would have served as an up-to-date advanced directive. Cardiopulmonary resuscitation would not have been ordered and she would have not had suffered that indignity. Because of her severe and profound dementia the advice of the physician staff likely would have been that after her first hospital admission she should be treated for any complications in the nursing home and if unsuccessful placed in hospice. If conflict arose the appropriate care committee would have been consulted and most likely would have agreed with the physician’s plan, as it was reasonable and humane. With committee concurrence the family would have been told that third party payers would not be responsible for other than nursing home and hospice care. Knowing that, the son would have most likely agreed with the plan and family conflict would have been avoided. Our society would have saved significant resources which could then be devoted to universal coverage and other worthwhile goals.

Thursday, January 8, 2009

The Road to Universal Coverage

1)The U.S. Healthcare Workforce

The U.S., at this time, does not have an adequate healthcare workforce to deliver excellent universal coverage no matter how much money is spent.

a)The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician extenders as a thin next layer, and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of young Americans pursuing a career in nursing.

b)The physician workforce in the United States is woefully lacking in primary care. Today, only 1/3 of physicians practice primary care and 2/3 practice as specialists. This is an inverse ratio from other developed nations with much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care, but it will take decades by this method alone to reverse the aberrant ratio of primary care to specialists doctors. We need a system in which many of our specialists also practice primary care.

2) Beneficial Care, A New Admitting Form and Appropriate Care Committees

Medical care must be of high quality and deliver value for the dollar. This means that only beneficial care can be given, using judgment on a case by case basis determined by each patient’s individual overall health situation. This must be done in tandem with expanded coverage or excess costs will quickly bankrupt the system. We need to deal with consumerism and the commercialization of medicine that has become the American healthcare system. There are many examples of excess use of technology - the Courage trial demonstrating overuse of procedures in coronary artery disease, over half a million deaths yearly in intensive care units of patients who belong in hospice, etc, etc, - that must be addressed immediately and for which ample data is presently available. If not done the percent gross domestic product (GDP) devoted to health care in the U.S. will continue to increase. The economic distortions to our economy will continue, regardless if paid for by private means or taxes. We must quickly decrease our percent GDP devoted to healthcare while providing universal coverage, which, with the proper controls (hospital admission form and appropriate care committees) can be immediately achieved, or this laudable goal will cause more economic hardship for our people.

3)A Healthcare Board (synonymous with Health Care Bank)
This board would be fashioned after the Federal Reserve Bank taking the management but not the responsibility of healthcare out of the hands of Congress is an idea whose time has come (see posting on the "Health Care Bank").

Sunday, January 4, 2009

Now It's Your Turn - Tell Us Your Stories

I hope 2009 is a good year for you all.

For the past eleven months I have been presenting ideas about health care reform here on my blog. Many of these postings are accompanied by stories about patients with whom I have had personal knowledge. In my travels, when discussing my book and or my blog, I have found that almost everyone has a story about our healthcare system. Most, but by no means all, have involved end-of-life situations. I suppose this is because these experiences are so intense and personal, and, in so many cases, our end-of-life care is so irrational. In a sense, the irrationality of our end-of-life care is a bell weather example of the irrationality present throughout our entire health care system.

There are, however, many wonderful stories we also need to hear and read. So, I am inviting all of you who visit my blog and are so inclined to summarize in a comment one of your experiences, good or bad, with our health care system. I will respond to each of your postings.