Can we really afford any more medical advances?

Nurses General Nursing

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Medicine has come up with more wonder drugs, procedures, technologies than ever before. All of it very expensive, too. It all comes at a big price. It's becoming more and more difficult to deliver it to everyone.

Have we gone as far as we really can practically manage, without going broke? More and more can be done, but will it end up bankrupting us? Obama is talking a lot on controlling Medicare costs before it goes bankrupt.

There's a lot of talk of how socialized medicine, universal coverage, is our salvation. But, is it really? I seriously doubt it.

How much does one MRI machine cost? Astronomical. Think of all the other expensive machinery in the hospital. And, at what cost is the regulatory burden? Then add in all the other costs. After that, figure in a bunch of heroic new surgeries and treatments. How about surgery on babies in the womb? Genetic manipulation, cloning body parts, new expensive treatments for AIDS patients with drug regimes totaling in the tens of thousands a year. Then add on all the new dialysis patients expected in the wake of our obesity/diabetes epidemic.

I don't think we can afford much more of this.

Daniel Callahan on Amazon: http://www.amazon.com/exec/obidos/search-handle-url/ref=ntt_athr_dp_sr_1?%5Fencoding=UTF8&search-type=ss&index=books&field-author=Daniel%20Callahan - though there are a lot of 'what the?" hits, the top few are all him :)

The full titles of the trilogy are Setting Limits: Medical Goals in an Aging Society, What Kind of Life: The Limits of Medical Progress and The Troubled Dream of Life: In Search of a Peaceful Death.

I'm not sure if Vicky's moderator note was directed at me but in any case I want to be clear that my "if you come from a 'treat at all costs' mindset" comment was meant to be informative about his tone and was not directed at anyone.

I'm certain it wasn't. And thanks for the links! I like this guy.

One fact is that prevention, though important, only delays the inevitable end of life decisions. Eventually even Jack LaLanne will be on death's door.

Agreed. There are two issues here: healthcare costs incurred during the course of life that can be reduced through prevention, and healthcare dollars wasted on futile end-of-life interventions.

Here is something interesting regarding end-of-life and hospital care. A 2008 study found that hospitals designated as "aggressive" in doing more procedures did not equal better outcomes compared to less-aggressive hospitals. In fact, the longer the patients were in the hospital the more their risk increased for hospital-acquired infections and medical errors.

I hope this data is used to guide reimbursement (and therefore USE) of these procedures.

"The general principle is that greater intensity of care is not better, and at the high end can actually be harmful," Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care.

http://www.nytimes.com/2008/05/30/nyregion/30hospitals.html?_r=1&scp=1&sq=public+private+hospitals&st=nyt&oref=slogin

Great discussion, thanks for starting it!

Specializes in ER.
I'm talking about financial REALITIES. Anyone familiar with me here knows I'm not all about money, I think that's a very unfair accusation.

Hemodialysis is another example where it is provided to anyone who needs it, in spite of their level of compliance or potential outcome.

That's not so in most nations that have socialized medicine. The UK rations dialysis.

Financial realities don't go away with heartfelt wishes for Peace on Earth and Open Heart Surgery to all. All these new medications, techniques, discoveries cost big bucks!

I did say if it's not about the money, I apoligize, you could be fair also.

Financial realities? Peace on Earth? Open Heart Surgery to all. Of course all these things cost alot of money and that is not going to change. The unfortunate reality is that if you live in a european country and you're over the age of 65 and you have an MI, you will not be having a CABG, you will only receive pallative care. What if that 66 year old were your grandfather and he had a great quality of life which could be extended by 15-20 years with a CABG? You could be a Type I diabetic due to no fault of your own and you're denied dialysis? I think socialized medicine is wrong. Dead Wrong.

In our country many people die because they don't have insurance, they don't have the money to pay for dialysis, or open heart surgery, it happens on a daily basis all over our great country. The only ones fortunate to get these life saving treatments, regardless of the expense, are those who know how to work the system.

I don't care how much a surgery would cost to save a child in my womb, the reality is, it does cost money but at least in the US we have the opportunity to save our loved ones regardless of their age or lack thereof. And I am talking quality of life/end of a life in contrast to end of life care where there is no quality of life.

Specializes in NICU, PICU, PCVICU and peds oncology.
I am sure when Salk developed his polio vaccine, and Pasteur developed penicillin and homogenized milk people wondered how in the world would the amount required to vaccinate every person, produce enough antibiotics to treat every person, and how do to treat all that milk from all those cows for all those people was considered quit a financial and heroic challenge. Where would we be today if the challenge was not taken up? We owe it to future generations to continue to pick up the gauntlet and overcome our challenges...that is why the human race has survived..it is all about survival not just of one person but the whole of mankind.

This sentiment is spot-on. With certain caveats. Public health protection is paramount to keeping nations healthy.

(I'm sure Lois Pasteur would love to take credit for peniciilin, but he had already been dead 33 years when Alexander Fleming discovered its antibiotic properties by accident.)

We have to stop keeping the living dead alive. Three strokes, no mentation, and INR's thrice weekly, blood thinners, anti-seizure meds, beta-blockers, yada yada yada - when do we let people go?

This situation is even worse in peds, believe me. Why are we transplanting hearts into children who have no renal function, and then keeping them in intensive care for months and months so they can have CRRT while they grow big enough for a kidney transplant? Of course the ICU stay will also include multiple CT scans and MRIs, x-rays, lab work, medications, surgical procedures, equipment and human resources. And when that same child arrests for more than an hour, then arrests again later the same day, why do we give our all to get ROSC and then allow the family to choose not to go for a head CT to ascertain the damage caused by the prolonged resus? Why do we list for cardiac transplant and implant an LVAD into a young adult who has already outlived the life expectancy for the genetic disorder that caused the cardiomyopathy in the first place and has also caused irreversible renal failure? This sort of ethical and moral morasse causes no end of distress to the nurses I work with. Selection of patients and intensity of treatment could be more judicious and would spare the system the expense of prolonging futile treatment as well as aid in retaining the nursing staff. I can't tell you how many nurses have left our unit never to return after being assigned to some of these special cases for weeks on end.

I did say if it's not about the money, I apoligize, you could be fair also.

Financial realities? Peace on Earth? Open Heart Surgery to all. Of course all these things cost alot of money and that is not going to change. The unfortunate reality is that if you live in a european country and you're over the age of 65 and you have an MI, you will not be having a CABG, you will only receive pallative care. What if that 66 year old were your grandfather and he had a great quality of life which could be extended by 15-20 years with a CABG? You could be a Type I diabetic due to no fault of your own and you're denied dialysis? I think socialized medicine is wrong. Dead Wrong.

In our country many people die because they don't have insurance, they don't have the money to pay for dialysis, or open heart surgery, it happens on a daily basis all over our great country. The only ones fortunate to get these life saving treatments, regardless of the expense, are those who know how to work the system.

I don't care how much a surgery would cost to save a child in my womb, the reality is, it does cost money but at least in the US we have the opportunity to save our loved ones regardless of their age or lack thereof. And I am talking quality of life/end of a life in contrast to end of life care where there is no quality of life.

The bolded statementhas been arrived at through a lack of understanding of how socialized health care works, at least in Canada. The cases I've described above are a product of socialized medicine... Do these children seem to have been denied anything? There is no difference at the other end of the life span either. This thread: https://allnurses.com/nursing-news/doctors-refusing-continue-311111.html describes that quite succinctly.

But this isn't a discussion about socialized health care, so let's not go too far off the beaten path. Should we stop looking for newer and better ways to restore health and maintain life? I don't think so. I do think we should establish clear-cut criteria for the implementation of these new therapies, and have a mechanism for review when these criteria are ignored. Reasonableness, responsibility and accountability would go a long way to keeping costs in line.

Specializes in Medical.
The unfortunate reality is that if you live in a european country and you're over the age of 65 and you have an MI, you will not be having a CABG, you will only receive pallative care.

I don't know about the EU but in Australia (which also has universal health care) people over 65 absolutely have CABGS. I'd like to point out that there you can have an MI and survive even without CABGS, so palliative care is really pretty rare unless there are other factors involved.

You could be a Type I diabetic due to no fault of your own and you're denied dialysis? I think socialized medicine is wrong. Dead Wrong.

As I write this I have any number of multiple morbidity patients on dialysis - from diabetes (ah, the spots we'd have available if there were no diabetes) to dementia. I'm by no means saying this is a good or desirable thing, but it's absolutely not the case that people are excluded from having therapies because of random diseases. The amount of misinformation (this isn't aimed at any particular member) flying around about universal health care never fails to amaze and shock me.

I don't care how much a surgery would cost to save a child in my womb, the reality is, it does cost money but at least in the US we have the opportunity to save our loved ones regardless of their age or lack thereof. And I am talking quality of life/end of a life in contrast to end of life care where there is no quality of life.

And in Australia and the UK and (as far as I know, every Western country with universal health care) you can have any treatment you like if you can pay for it. The only difference is that if you can't afford it you don't miss out on having basic health care - and that includes dialysis, transplantation, ICU, NICU, fetal surgery, rehab, and subsidised medications.

However, as Callahan said in the article so thoughtfully provided by Suesquatch, we still face the issue you do, just a little further down the track. The point is less how health care is paid for and more about revisiting our ideas of what constitutes ordinary care, particularly for those coming toward the end of their lives, regardless of what age they are.

There's a magnificent, though highly controversial, book by John Hartwig called Is There a Duty to Die? about the burdens an individual insisting on full medical treatment can have on their family, particularly (as he's an American author) when the cost of that care comes from private funds. It's more controversial than Callahan, and there are a number of dissenting responses included after the main section, but it makes for very interesting reading.

Specializes in ICU/Critical Care.

If people are going to make assumptions regarding socialized medicine in Australia or Canada or any European country for that matter, at least have facts to back it up. It may not be the greatest system but hey it's something. Everyone has a right to healthcare, socialized or not. Anyhow, thats all for another thread.

Specializes in Medical.

I think part of the problem is that in the last 100 years we've significantly changed our perspective about who should survive. In the first session of a professional ethics class I took a few years ago, we were given a hypothetical that I'd come across before. I won't go in to all of the details, but it boils down to: an 8 year old girl hasend-stage renal failure and will die without a transplant. She's unlikely to get an unrelated match in time, so her family are checked and her father's a good match. However, before the doctor has an opportunity to disclose this the girl's father tells her that he doesn't want anyone to know he's a match because he doesn't want to donate his kidney. What should (that's a moral 'should') the doctor do?

I was the only health care professional in the class, and kept quiet as the ten or twelve others expressed horror at the father's inhumanity and presented varying strategies of coersion that the doctor could use, from subtle influence to threatening to tell his wife.

Then the lecturers, knowing I was a nurse, asked me what I thought. I said I thought the doctor should respect the father's decision.

My classmates were... not happy. They returned to the fact that the child would most likely die without her father's kidney.

I presented a variety of reasons why the doctor had a moral obligation to respect the father's decision. I added some facts that the group were unaware of, like length of survival post transplant, likelihood of rejection, and complications of long-term immunosuppressants, like an increased incidence of cancer. This is not because I'm opposed to transplantation in toto but because the group seemed to think that a transplant would leave the child with a normal life span free of further complications.

I was admonished by one classmate that I couldn't add details that weren't in the case, which is fair enough (although it's information the doctor would have). Even with those aside, there are known risks for the donor - a couple of years ago an Australian man died on the table donating a kidney to his child. However, what it boils down to is that children die. It's not fair and it's not comfortable to think about, but children die. And because my classmates were shocked at the idea of a hypothetical child dying, they were (hypothetically) prepared to smash medical confidentiality, commit an illegal act (blackmail) and threaten not only a man's marriage but his relationship with his dying child.

We have technologies that have increased the length and quality of our lives. They've also massively extended the morbidity of people who would have died (often, but certainly not always) peacefully and with a minimum of intervention, but now spend months or years in institutions having unspeakable things done to them.

It's not the tech, it's how we use it. And to use it better we need to revisit the fact, widely accepted until recently, that people die. Even children. We can spend vast sums of money extending the lives of the inevitably dying, but sooner or later that will come at the cost of failing to improve the welfare of the majority of people.

Specializes in ER.
If people are going to make assumptions regarding socialized medicine in Australia or Canada or any European country for that matter, at least have facts to back it up. Everyone has a right to healthcare, socialized or not. Anyhow, thats all for another thread.

I was talking about Europe and Europe only and I was not making assumptions. We have had patients in the hospital where I work who are over the age of 65, from Europe, who where told they were out of luck. A person in need of a quadruple bypass in which 3 of the arteries are over 90% occluded cannot survive by any other means than a CABG.

Specializes in ICU/Critical Care.
I was talking about Europe and Europe only and I was not making assumptions. We have had patients in the hospital where I work who are over the age of 65, from Europe, who where told they were out of luck. A person in need of a quadruple bypass in which 3 of the arteries are over 90% occluded cannot survive by any other means than a CABG.

What I would like to know is, why were they told that they were out of luck? Did they have some other co-morbitdities that made them not a good candidate for surgery? Were there other factors such as a lack of cardiothoracic surgeons? There has to be some other reason besides "Sorry you are out of luck." I'm just curious.

Specializes in Critical Care.
Specializes in Medical.
I was talking about Europe and Europe only and I was not making assumptions. We have had patients in the hospital where I work who are over the age of 65, from Europe, who where told they were out of luck. A person in need of a quadruple bypass in which 3 of the arteries are over 90% occluded cannot survive by any other means than a CABG.

Without getting into the merits of hypothetical patients over 65 with serious coronary artery disease, that's a far cry from

The unfortunate reality is that if you live in a european country and you're over the age of 65 and you have an MI, you will not be having a CABG, you will only receive pallative care.

It makes me wonder what other information was left out - like co-morbidities.

Specializes in ER.
what i would like to know is, why were they told that they were out of luck? did they have some other co-morbitdities that made them not a good candidate for surgery? were there other factors such as a lack of cardiothoracic surgeons? there has to be some other reason besides "sorry you are out of luck." i'm just curious.

ok, this is in the united states

new orleans - eighty-year-olds with clogged arteries or leaky heart valves used to be sent home with a pat on the arm from their doctors and pills to try to ease their symptoms. now more are getting open-heart surgery, with remarkable survival rates rivaling those of much younger people, new studies show.

years ago, physicians "were told we were pushing the envelope" to

operate on a 70-year-old, said dr. vincent bufalino, a cardiologist at loyola university in chicago. but today "we have elderly folks who are extremely viable, mentally quite sharp," who want to decide for themselves whether to take the risk, he said.

even 90-year-olds are having open-heart surgery, said dr. harlan krumholz, a yale university cardiologist who has researched older heart patients.

"age itself shouldn't be an automatic exclusion," he said. not every older person can undergo such a challenging operation, but the great results seen in the new studies show that doctors have gotten good at figuring out who can.

treatment guidelines by the heart association and other groups do not have age cutoffs for such operations. it's been up to patients, doctors and insurers to decide whether to risk it. http://au.ibtimes.com/articles/20081110/studies-elderly-fare-well-in-open-heart-surgery.htm

this is in canada:

making you wait will either cure you or kill you. a close friend's mother died waiting for heart surgery (waiting lists are a function of budgets). desperate, my friend had offered to pay the cost. he would borrow the money, if necessary. operate today. "sorry. we have an available operating room, and work-hungry nurses and doctors. but we're not allowed to accept private money from canadians." socialized medicine killed a canadian mother.

last year, another friend took his closest buddy, with a heart attack, to four toronto hospitals. turned away at each (there were available operating rooms, etc., but no staff, because no budgets), the buddy died at the fifth.

highly-talented specialists have fled our socialized system in droves since the 1960s; that socialized medicine exerts a depressing effect on scientific research and technology; that currently the u.s., which has too many specialists, is successfully luring away legions of good g.p.s; that because canadian political (and medical) elites are too implicated to admit the gross failure of socialized medicine, we are going to be treated to another 30 years of compensatory policy adjustments and administrative band-aids designed not to make us healthier, but to keep us dumb, thankful, and most importantly - paying.

http://www.williamgairdner.com/the-failure-of-socialized-medi/

ok, i generally agree that we need some semblance of universal healthcare in this country. but be warned about what you are in for. you’ll remember that, a couple days ago, i told you my dad had a minor stroke because he has 69% blockage in his carotid artery.

well, today he found out that they will not operate on him. he has to have 90% blockage in order to be considered.

if you want socialized medicine in this country, know what you are getting into. the decision about my dad was not made from a health perspective. if it was, he’d have been in the operating room already. it was made from a rationing perspective, and i am ****** off royally. it would not have happened here. you can talk all you want about the people who don’t have healthcare in this country, and i definitely sympathize with that because my ex-partner’s parents, who i love dearly, are ill and don’t have insurance. but if you do have health insurance, and if your carotid artery is 69% blocked you’d get the operation here.

this is england:

london people have a “right” to health care. that is just not true. the british government says that, at any one time, there are about a million people waiting to get into hospitals. according to the fraser institute, almost 900,000 patients are on the waiting list at any point in time. and, according to the new zealand government, 90,000 people are on the waiting lists there. many of the people waiting are waiting in pain. many are risking their lives by waiting. and there is no market mechanism in these countries to get care first to people who need it first.

british doctors see 50 percent more patients than american doctors do, and, as a conse-

quence, they have less time to spend with each patient. in britain, the typical general

practitioner barely has time to take your temperature and write a prescription. and

even if they discover something wrong with you, they may not have the technology to

solve your problem. among people with chronic renal failure, only half as many canadians as americans get dialysis, and only a third as many britons.

the american rate of coronary bypass surgeries is three or four times what it is in canada, and five times what it is in britain.

britain is the country that invented the cat scanner, back in the 1970s. for a

while it exported more than half the cat scanners used in the world. yet they

bought very few for their own citizens. today, britain has half the number of cat

scanners per capita as we do in the united states. a similar problem exists in canada.

i’m especially interested in the elderly, because i find that—not only in britain and canada, but also in the united states—when people have to make decisions about who is going to get care and who is not, they choose the younger patient. surveys of the elderly breast cancer, only one fifth die in the united states, compared to one third in france and germany, and almost half in the united kingdom and new zealand.

among men who are diagnosed with prostate cancer, fewer than one fifth die in the united states, compared to one fourth in canada, almost half in france, and more than half in the united kingdom.

http://www.cato.org/pubs/catosletter/catosletterv3n1.pdf.

in several countries with socialized medicine:

the percentage of the respondents in need coronary bypass who had been waiting for more than three months was 0% in u.s., 18.2% in sweden, 46.7% in canada, and 88.9% in the united kingdom. http://right-mind.us/blogs/blog_0/archive/2006/04/04/42753.aspx

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