Interested in everyone's opinion on this...

[JeffPT]

http://money.msn.com/health-and-life-insurance/article.aspx?post=4b6eafb1-26bb-484a-8f45-fb16fe92aec4

This is a short article that took me no more than about 2 minutes to read.  I'm going to voice my opinion and then let others chime in.  I'm sure some will disagree with me and others might not. 

I think that medicare needs to deny patients some forms of care if their condition is such that they have no chance of getting better.  At first glance, that might seem heartless, but I think exactly the opposite is true.  Sometimes, ending the services that prolong a life full of suffering can be the second best thing you can do for someone in those situations (the first being helping them end their own lives).  I've given people with Alzheimer's physical therapy treatment.  I've given people with dementia physical therapy treatment.  I've charged hundreds and thousands of dollars to medicare to provide the treatment, all the while knowing that within 2 weeks of me getting Mrs. Smith to walk an extra 25 feet, she won't be doing it any more.  Huge sums of money... wasted.  And it happens all over the country, every single day. 

Before judging me on this, please understand that I've had conversations with many of them that are just mentally stable enough to tell you they are 'ready to go'.  And of the ones that don't, many of them are the ones that have no idea what's going on around them.  Almost all of them have DNR orders, which means if something bad happens, you don't try to be the hero and save their life, because they want out.  They have zero quality of life.  They are tremendous burdens on their families and if they knew they were in the state they were in, they would ask you to end their lives on the spot.  Just take a stroll through a nursing home, look at the people, and ask yourself if you'd ever want to be that person in the wheelchair the entire day, attached to the colostomy bag, babbling incoherently to the person next to them.  It's horribly sad.  Horribly sad.  I've spent so many hours trying to get them to be stronger and healthier when every instinct told me that the best thing I could do for them is put a pillow over their face.  It's the main reason I left and went into orthopedics.   

On the other side, I've also charged medicare lots of money for people who really DID need it, and was glad to do it, but there are lots and lots of people who are just being treated, and kept alive so the system (nursing homes, DME vendors, pharmacies, etc) can screw them out of all the money they have in the world.   

The article, I believe, was going for a 'feel good' message, but it didn't make me feel good at all.  Maybe your opinion is different.  I'd like to hear it. 

[Nam]

I feel people have a right to do with their bodies as they wish, including suicide. However, even those who wish to live have every right to live. Meaning, even if it'll cost an arm and a leg (figuratively) they have that right, too. Does it cost money? Sure but I don't really think it's the money, I think it's because we (the US) do not have socialized health care like most other Western countries do. And we should. Yes, ObamCare is a first step but it needs to be improved.

-Nam

[Garja]

I think I generally agree with what you are saying Jeff.  I would say that I believe that medicare should help seniors live comfortable lives, and should help to extend those lives up to the wishes of the patient... but I dont think we should be trying to actively try to 'save everyone'.  And I have to agree with Nam on this one as well, and support a persons right to "choose to opt out" due to severe illness.

[on:bread:alone]

i'll preface this by saying i did not watch the video. i have no audio at the moment.

on the whole, i agree... but it is dicey ground upon which to tread. in my opinion, life itself is a terminal disease. death is inevitable; it is the only promise that life is gauranteed to keep. in that respect, the administration of any medication or treatment is in and of itself an excersize in futility. we can come up with all kinds of ways to improve the quality of life for any number of people, healthy or otherwise, but in the end none of it will matter. we all die.

any of you who have read any of what i have written in my time here could be well aware that i harbor some rather unconventional ideas towards pretty much everything. it's not that i'm a rabble-rouser; i consider myself a realist. i support euthanasia, as dr. kevorkian (who was way before his time) prescribed... or rather physician assisted death. the human body, in my expressedly unorthodox opinion, was simply not meant to live as long as we've been able to make it live. by one's late 30's to early 40's, generally the teeth start to fall out and rot (but we have dentistry to counter this), the joints and bones begin to deteriorate (but we have vitamin supplements and so forth), and one has to become considerably more pro-active in extending their lives in a healthy manner, whereas children (and this again is a very generalized statement) are more resilient and don't have to worry about it so much.

this also plays into the whole "seeking god in the eleventh hour" routine, because as we get older, we become more aware of our mortality, and a great many succumb to religious pressure... which i find detestable in the worst way.

i have, several times in my life, required medical attention. however, if we as mammals had not built our civilizations over the foundation of the fear of death, i may well have died several times over. it's natural selection. kill or be killed. will the coyote starve to death, or chew off it's own leg and die of gangreen? ultimately, it makes no difference whatsoever.

i think governemnt programs like hospice, which are designed to make the terminally ill as comfortable as possible in their twilight hours are wonderful programs to have. however, i think that prolonging life to avoid death is a waste of valuable resources.

[Nick]

People should be able to determine how their lives go.  Problem is so many get to a point where rational decisions can no longer be made.  LIVING WILLS are so important and letting people know long before hand what your wished are.  Quality of life is so much more important to me than longevity.  I wish assisted suicide was available in all 50 states.

[JeffPT]

I think I generally agree with what you are saying Jeff.  I would say that I believe that medicare should help seniors live comfortable lives, and should help to extend those lives up to the wishes of the patient... but I dont think we should be trying to actively try to 'save everyone'.  And I have to agree with Nam on this one as well, and support a persons right to "choose to opt out" due to severe illness.

But if the patient is not capable of expressing their wishes, what do we do with them?  Do we draw some sort of line somewhere?  Do we give them some sort of cognitive test and if they fail it, we stop giving them care?  Is it even conceivable to request that someone else's life be ended without their consent (if they can't give it), based on their condition?  I'm not saying I have the answer, I am trying to find the right way to approach it. 

The issue is a lot like abortion if you ask me.  People all draw the 'when is a fetus a child' line in a different spot.  It will be equally hard to draw the 'when is a life not worth living' line.   

[earthfreak]

It is a really tricky question.  I find it to be really different from abortion, but that's another topic.

I have euthanized a number of pets, and usually the choice is pretty clear.  My mom (who I did not get along with, which makes it WAY complicated) has had dementia for years and has been in a nursing home for (fewer) years as well.  I would have euthanized her a long time ago if she was a dog, just out of concern for her.

As for making your own choice, I think assisted suicide should be available, period. It's complicated, because I would never want to see people pressured, but I would hope it would be available to anyone who needed it. 

That's different, however, from denying medical care that would make life possibly less painful for people who are in a terminal situation without the option of assisted suicide. 

God, we're crazy

[ParkingPlaces]

You're talking "death panels" here. Of course we already have those, most often in the form of insurance company clerks who decide, without any medical training, what their company will and will not pay for. And of course Medicare has some strange requirements that I assume at times speed up the funeral date for some folks.

No system can be perfect. And the expectations any patient or patient family member can vary greatly. I am in reasonable health and 65, but I do not want to survive past a certain level of health degradation when a return to normal is not possible. So I'm fine with what you propose; using a realistic health assessment from competent health professionals. (And based on my experience with hospice, I would almost rather have experienced nurses tell me or my family my prognosis than a doctor. They seem to have fantastic instincts.) Anyway, I'm fine with it. But some people are not. And I think we should listen to all sides of this issue before deciding what would be best.

My father died about two years ago. He was in great health until he was 86 and suffered a burst appendix. The next three years were hell for him, and included to serious falls that led to broken bones, along with rapidly advancing prostate cancer which weakened him badly. I've no idea how much those last three years cost, medicare and insurance-wise. I was not involved in that aspect of his life. But I'm guessing half a million, minimum. And for a person of that advanced an age that was probably not the best use of either financial or medical resources. But I don't know when and where the plug could have been pulled earlier. And I've no idea how to decide that.

It would be interesting to know if this suggestion from JeffPT would be the best way to save money with health care, or if there might be other things we could do that would save more and cost less. Are the morbidly obese costing more than we should be spending, regardless of age? Should smokers and others that openly abuse their bodies get the same level of care as people who make an effort to eat and live more wisely? What other variables that differentiate people besides being almost dead might be worth exploring as potential cost-saving measures.

Since I don't hang with doctors much, and I don't need medical care much, my familiarity with the various ways we might be wasting money is minimal. And I won't take is personal if JeffPT recommends that I not get any PT because I'm over the hill, literally. But I'm guessing that not all will agree with either JeffPT or myself.

[JeffPT]

It would be interesting to know if this suggestion from JeffPT would be the best way to save money with health care, or if there might be other things we could do that would save more and cost less.

I don't really feel like I'm suggesting anything other than not treating the people that shouldn't be getting it in the first place.  The problem is that everyone is going to decide that point differently.  I can tell you without a doubt, that nursing home therapy providers across the country are probably going to be rolling in medicare dollars with a result like this.  And there will be lots of therapy done on people who shouldn't be having it done.  Billions of dollars worth. 

Since I don't hang with doctors much, and I don't need medical care much, my familiarity with the various ways we might be wasting money is minimal. And I won't take is personal if JeffPT recommends that I not get any PT because I'm over the hill, literally. But I'm guessing that not all will agree with either JeffPT or myself.

Well, it depends what sort of '65' you are.  If you're 65, living in a nursing home, wheelchair bound, need someone to feed you through a straw every day, taking pain pills 4 to 5 times a day, can't speak coherently, sleep 85% of the time, have no family visitors, have a DNR status, urinate and defaecate into a diaper every day, can't hear well, see well, have bed sores on your ankles and your coccyx, and are stuck on 4 liters of oxygen, I don't want to give you PT.  I'd rather help you die. 

If you're the opposite of that, or if you have some big problems but are still cognitively fit to make your own decisions about therapy, and you'd like to have it, then its money well spent to try and get you back up and running again. 

[HAL]

I think that medicare needs to deny patients some forms of care if their condition is such that they have no chance of getting better.

It says -

Medicare will pay for such services if they are needed to 'maintain the patient's current condition or prevent or slow further deterioration,' regardless of whether the patient's condition is expected to improve."

What's wrong with that? I think this kind of thing is easy to criticize until it affects you. This country can afford to do these things. We need to tax the rich more.

[JeffPT]

What's wrong with it, (again, my opinion only) is that sometimes deterioration is better for the patient because it gets them closer to where they might rather be anyway; gone. 

When they say 'slow the deterioration', in therapy terms, this is what they mean... Say you have a resident who normally walks to and from the dining room with someone helping them (because they don't really know where to go, even though they've lived there for years) and it's maybe 100 feet to get there.  Then one day, she gets sick or is too tired to do it, and for a few days she has to be brought to the dining room in a wheelchair.  When the nursing staff tries to get her back walking again, she can only do 75 feet.  They then tell the therapy department, and an evaluation is generated, in hopes of getting her to walk the additional 25 feet again.  So we work on her for a good while because she can't do a home exercise program on her own, so it's all one on one (cha-ching for the therapy department).   It might take 2 to 3 months to get that additional 25 feet out of her.  At somewhere near 100 dollars per visit, 3 times a week, for 3 months, you're talking a lot of money for that 25 feet.  Throw on top of that the fact that in another 2 or 3 weeks, your gains will probably be gone, quite often because the CNA staff prefers to get her to the dining room in the wheelchair because it's quicker than walking her.   

All of that, on top of the fact that the woman in question (if she were suddenly completely coherent and knew the shape she was in) would most likely ask you to end her life immediately.  Keep in mind, she's NEVER going to get better.  So the question is whether or not it's money and time well spent.  For the case I mentioned above, which is extremely common and is the reason a huge portion of the people in long term care settings are getting therapy, I say it's not. 

For certain people, I agree it might be money well spent, but I'd have to say that more often than not, it's poorly spent.  That is my personal experience with treating that population.  Maybe others feel different. 

I hope that illustrates what I see wrong with it. 

I agree we need to tax the rich more.   

[Graybeard]

I am assuming that you are suggesting that, in the cases you describe, treatment, such as it is and because it is ineffective, is withdrawn.

I agree that ineffective treatment should not be available. Much of such treatment is based upon someone in the distant past suggesting it – others take it up as gospel. But is it ineffective?

The contact that they have with someone like you who (apparently) has their interests at heart and hopes to improve their lot, is very important to them – that contact alone can ease symptoms and lessen the speed of the disability – the placebo effect. We are talking a slight improvement in the quality of life.

Without those like you, the patients' days are boring, uneventful. They have no experiences to share.

Medically ineffective, but perhaps uplifting.

[shnozzola]

   I believe this ends up like many other decisions.   Every individual case is different and has to be judged on its own by, hopefully, a caregiver with common sense and scruples.

   My wife is working on her LPN while employed at a retirement home.  She accompanied a 90 year old woman to the dentist this week.  My wife thinks it is amusing a woman of that age cares about her teeth.  In this case, the woman is using her own money.  She is sound of mind and has decided that this is what she wants to do.  I believe that if she was dependent on taxpayer money, she should only be given the money for minimal dental work if at all.

  If you're 65, living in a nursing home, wheelchair bound, need someone to feed you through a straw every day, taking pain pills 4 to 5 times a day, can't speak coherently, sleep 85% of the time, have no family visitors, have a DNR status, urinate and defaecate into a diaper every day, can't hear well, see well, have bed sores on your ankles and your coccyx, and are stuck on 4 liters of oxygen, I don't want to give you PT.

   The question for us all, is, as you take away the problems of the 65 yr old above, one by one, when do we draw the line?  For instance, what if this person has all these problems, but, has a spouse and 6 children who visit every week and insist on the best care possible, but only with taxpayer money?  Not enough - OK, what if all the problems exist except the patient has a sound mind with the large family, and sleeps normally - is that enough?  Not enough, add good hearing.  Is that enough?  How about if the resident wants to live?

If the family is in the picture with a patient with, say, advanced dementia, it seems their decision carries the most weight.  If no family, and the nursing home is making alot of money for keeping this person alive, again it seems there needs to be an outside decision maker with common sense.

 Added edit:
My wife gets extremely angry at other nurses that refuse to properly bathe the folks with dementia.  In fact it makes her blood boil that these people do not get the dignity that they deserve at the end of life.

[on:bread:alone]

i say drown 'em in the bathtub. =D

[JeffPT]

I am assuming that you are suggesting that, in the cases you describe, treatment, such as it is and because it is ineffective, is withdrawn.

I agree that ineffective treatment should not be available. Much of such treatment is based upon someone in the distant past suggesting it – others take it up as gospel. But is it ineffective?

The contact that they have with someone like you who (apparently) has their interests at heart and hopes to improve their lot, is very important to them – that contact alone can ease symptoms and lessen the speed of the disability – the placebo effect. We are talking a slight improvement in the quality of life.

Without those like you, the patients' days are boring, uneventful. They have no experiences to share.

Medically ineffective, but perhaps uplifting.

Actually, the treatment is often very effective. The vast majority of the time, I could get that woman her 25 feet and meet the goals I set out to achieve.  But she would not keep them, because her overall condition will only get worse over time.  It has no chance of getting better. 

I agree that sometimes the physical contact can be great for them.  But that's not why I'm in there.  I get paid way too much money to just be a friend to them.  Don't get me wrong.  When I'm in there, I do my utmost to make sure they get all the care I can give, including the emotional support, but that's really not my job.  There have been many times when I've left a room fighting back tears. 

I remember this one guy.  He was a Lt. Commander in the Navy during WWII.  He had pictures all over his room with his ship and friends, including 2 other brothers who were also Navy men.  You KNEW this man commanded respect when he was young, but when I was seeing him, he had no control over his bowel and bladder function, couldn't hear unless you screamed in his ear, and constantly asked where he was supposed to be and what he was supposed to be doing.  He told me several times that he 'just wanted it to be over'.  What do you say to that?  The best thing I could have done for him was to end it.  That was 4 years ago now.  I don't know if he's still alive.  I've got many stories like that. 

(As a side note, if God is real, He can go fuck himself for allowing that to happen).
 

The question for us all, is, as you take away the problems of the 65 yr old above, one by one, when do we draw the line?

Yes, exactly.  That's why I equated it somewhat to the abortion issue, where you have to draw the line at life versus non-life. 

My wife gets extremely angry at other nurses that refuse to properly bathe the folks with dementia.  In fact it makes her blood boil that these people do not get the dignity that they deserve at the end of life.

Then she must get angry a lot.  The people responsible for the bathing are paid minimum wage or very close to it.  It's the CNA's duty most times. Do you really think a minimum wage person is going to give an elderly person the dignity and respect they deserve?  It happens, but its more uncommon than not.