Monday, December 14, 2009

Cardiopulmonary Resuscitation

In my book, In Defiance of Death: Exposing the Real Costs of End-Of-Life Care, I discussed the uses and abuses of in-hospital cardiopulmonary resuscitation (CPR). This procedure involves attempting to restart the heart after it has stopped beating. I quoted a paper that found only 10.5% of these patients were alive one year later. I mentioned that if we could decrease the number of resuscitations in half, by excluding those patients with known terminal disease, not only would we save dollars, but more importantly we would allow thousands of patients to have a more dignified and peaceful death.

I quoted Dr. Blackhall who, in The New England Journal (1987), discussed the concepts of patient autonomy and physician responsibility. Basically, he said that if the medical assessment is that CPR has even a remote chance of success it should be offered and the patient with autonomy has the right to refuse the procedure. However, if there is no chance of success, physician responsibility would dictate that CPR should not be done regardless of the wishes of the patient/family. In these situations Dr. Blackhall concluded that both patient and physician must understand that modern medicine cannot indefinitely postpone death.

I also pointed out that since the early 1960's CPR is performed in the hospital as the default position unless there is a specific do not resuscitate order (DNR). This frequently leads to confusion, with CPR being attempted in the majority of cases when it is obvious that it would not be successful. This is the reason that a small percentage of patients receiving CPR leave the hospital alive and fewer still are alive a year later. I suggested a new hospital admission form that would make CPR an ordered event and create an updated advanced directive with physician input to ensure medical feasibility. I also suggested an appeal mechanism in cases of misunderstandings or differences in opinion.

So what is the latest data? Are we using CPR more or less wisely? Dr. W.J. Ehlenbach and colleagues recently published results using Medicare data (reimbursement codes) from 1992-2005 in the July 2, 2009 New England Journal of Medicine. They found 18.3% of CPR patients left the hospital alive. There was no increase in the survival rate over this time course. They found an incidence of 2.73 CPR attempts per 1000 Medicare hospital admissions with survival less for men, the most elderly, those with co-existing disease and those admitted from skilled nursing homes. Strikingly they found that the proportion of patients dying in the hospital having undergone CPR actually increased during this time period. Fewer survivors of CPR were discharged home over the course of the study. People of African descent had higher rates of CPR but with less survival.

Is it just CPR that is now being increasingly used more inappropriately, or is it a reflection of the present style of medicine in this country? In my mind there is no doubt that it is a reflection of our present medical culture. There are presently no mechanisms whereby physicians collectively attempt to use our ever-expanding medical arsenal in an individualized rational manner. We presently have a business model in what is fundamentally a non-business enterprise. These are some of the reasons why we spend much more per person than any other country, have millions uninsured and inferior outcomes. Until these and other basic problems (i.e. lack of primary care, the politically driven Medicare payment system) are addressed, I believe our present attempts at health care reform will be unsuccessful.

Friday, December 4, 2009

Patient Knowledge Versus Consumerism

Patient education is a component of good health care. Patients should know how to stay healthy and, if necessary, care for disease processes. However, when health care becomes like any other consumer item, the whole process becomes distorted. Unlike consumer products today’s medicine is extremely complex with real limitations as to what can be accomplished. Ignoring these limitations leads to excessive testing and treatments, i.e. consumerism.

It is advantageous for a patient working with a trusted physician to understand the necessity to control blood pressure, control diabetes, control weight and eliminate harmful habits (tobacco, alcohol, illegal drugs, violence, etc.). Every literate American has access to abundant sources of information regarding health issues. Unfortunately, because of dysfunctional reimbursement policies, driven by Medicare as the nation’s largest insurer, for many patients there is little quality time between physician and patient. It then becomes difficult to develop the healing relationship so important for good health care. Frequently patient education develops into unrealistic beliefs in the power of medicine with inappropriate expectations leading to consumerism. In complex situations in patients with multiple health issues there is no substitute for medical judgment. This can only be obtained with formal training and years of experience.

Indeed it takes more training to take care of seriously ill patients than to fly a jet liner. Yet it is inconceivable that a jet pilot when facing a problem, instead of using his experience and judgment, would have the passengers vote on what to do. However, unlike the pilot, in today’s medical practice it is common for physicians to place the task of medical judgment on the patient/family frequently resulting in irrational care. This often leads to patient suffering and the wasting of valuable resources.

This exaggerated sense of patient autonomy along with the fear of legal action has augmented medical consumerism. This problem has been enhanced by drug and device advertisements directly to the public and by the medical profession’s undue reliance on the legal system to decide what are, in effect, medical questions. Instead of our various medical societies forming referral mechanisms to help decide difficult issues, hospitals and doctors have abdicated this responsibility to the courts with the result being an ever-present fear of legal action.

As long ago as October 16, 1975 Dr. Franz Ingelfinger, then editor of the New England Journal of Medicine, wrote about physicians allowing the legal community to be the referee in difficult medical issues. He wrote:
“Serious questions may also be raised concerning the propriety or usefulness of legal proceedings when essentially medical questions are at issue…..dependence on the lawyer in reaching essentially medical decisions will continue, however, unless organized medicine can develop its own effective system of in-house arbitration…..”

It should be noted that till this day our medical societies have not answered this challenge. Again, in May, 1994 (New England Journal of Medicine) while discussing the Baby K court case, an encephalic baby with no chance of recovery, George J. Annas had a similar message. He commented that for medicine to avoid becoming a consumer commodity and thus unbearably expensive requiring control by payers, physicians will have to set standards and follow them. Again organized medicine did not and has not responded.

A few weeks ago (November 2009) a talented second year resident told me that, in his opinion, American medicine is no longer about treating patients’ problems. It has become a hospitality industry focused on customer satisfaction regardless of the appropriateness of the medical plan.

For health care reform to be successful we have to insist that our medical societies set up procedures so that patients are treated as individuals, each with unique needs. At the same time mechanisms must be established so that we uniformly practice high quality medicine with evidence-based use of resources. We must have expanded peer review so that difficult situations and overuse can be quickly resolved using medical experts.