All right, now I know that this is going to touch on a few peoples "sensitive areas" but I wondered what other nurses thought. It seems to me that only in America is it considered a failure when you die--sometimes death is treated as an insult rather than the natural function it is. I have read that more money is spent on healthcare during pts. last 30 days of life than during their entire lifespan. Too many times patients that we know are going to die end up costing the health care systems ever increasing amounts of money in an attempt to save them from dying.
So is it time to change the public's perception of death and encourage palliative care and hospice more? Does the USA need to adopt guidelines as to what care should be provided for certain medical conditions? And that patients, ones that we all know will be DC'd to a nursing home or to a private residence to eventually die but are kept alive with vents, should be treated with hospice instead of medical care? I heard on the news last month that there are 10,000 people that are home ventilator dependent patients here in the USA.
What brought this up was a case...the pt. is 102 years old, has dementia, and fell, sustaining a compound fracture to an extremity. After surgery, a revision to the surgery, then pneumonia, many days in the hospital, an infection of the external fixation site, more pneumonia, several more days in the hospital, now in a nursing home for IV antibiotics...and she is still a full code per family's wishes. When is enough, enough?
A lot of these pts. end being paid for by tax dollars. Is it time to ration healthcare as a way to control costs and help make healthcare affordable/accessable to everyone?
It made the news this summer, when an Oregon woman on Medicaid found out that the state wouldn't pay for a $5000 drug for her re-emergent lung cancer, but they would pay $50 for suicide drugs.
The actual alternative isn't really any better, though, is it? Just a simple denial of coverage for the lung cancer drugs (since the chance of their substantially increasing the length or quality of life is minimal) and that's it.
If someone could propose a system or show a model anywhere that provides healthcare to the entire populace without restriction on services I'd love to see it. The system in the UK uses local boards to decide what meds/services are provided in their area. You could be denied a med based on where you live.
A year ago I had a patient who woke up apologizing. When she was more oriented, she explained that in Canada she was over the age to have a knee replacement. But since she had funds, she came to the States and had the surgery done.
A person can easily come up with similar anecdotes of Americans who couldn't access needed care because their insurance denied coverage or the like. I'm not saying that means their systems are better, but I don't see such examples as demonstrating that the US health care system has more access to care than the UK or Canada.
It is a multi-faceted problem though. We do need to work to control costs, something which Congress seems unable or unwilling to do. Their approach is to just decrease reimbursment to healthcare providers which ignores the pressures that raise costs.
If rationing is out of the question, how do you propose controlling costs? I know I don't have any easy answers! Wish I did!
And by the way, no one is "[denied] health services" in this country.
Yes, people are denied health services everyday in this country. Hospitals want their money up front on "elective" stuff such as chemotherapy if you don't have health insurance. A friend of mine survived a rare form of cancer 2 years ago but her COBRA ran out. She was quoted $3200 a mth to convert her insurance from COBRA. She has not had a PET/CT nor any other CA workup in the since her last round of chemo. And she does have insurance now but with a $5000 deductible and 70% coverage, the hospital wants $7000 cash before they will do her workup....she is still paying off the bills from 2 years ago CA.
Specializes in Mostly: Occup Health; ER; Informatics.
As I have stated in other posts, and OPs have pointed out, we DO have health care rationing in the USA. It is covert, being performed financially by individual third-party payers (Medicare, Medicaid, commercial insurers, etc.), instead of being open as is done in the U.K. "No pay, no play" is the rule here.
An excellent set of articles/posts on rationing is at http://covertrationingblog.com. I have no affiliation with that author or site, but agree heartily with most of his observations.
For example: "While covert rationing (instead of open rationing, our only other choice) remains the driving force behind American healthcare, doctors and patients who want to form a traditional, fiduciary, and mutually beneficial relationship, are going to have to find ways of doing so that are not sanctioned by the official healthcare system."
Specializes in NICU, PICU, PCVICU and peds oncology.
Imagine if you showed up at work and were told, "Your patients today have govt insurance so you'll get $7/hr to care for them. This is how we control healthcare costs."
Oh, gee... my patients today have government insurance, and I'm being paid $45 an hour to care for them. I'm afraid your argument doesn't hold water.
"Medicare reimbursement rates for mammographies are well below the average cost of performing them (current rates are just under $70, compared to average costs in New York City of $120 to $140), causing many centers to stop offering screenings and leading to extremely long waits at the centers that do."
Medicare does control costs by underpaying providers. And that's a problem. But I don't know what the solution is either.
Between the costs of developing, producing and running new technologios and the skilled manpower needed to do all that, today's health care IS expensive. The insurance model of pooling risk and spreading the costs doesn't keep costs low because almost everyone will be needing to access this technology several times throughout their life & maybe on an on-going basis.
Given that, how do you keep costs down without rationing on some level?
That is a good question. I support rationing whether by personal economics or government health program. There is no way to provide everything to everyone. Sure, I'd love for everyone to get every medical treatment they need, that's just not practical.
I don't want the government or my insurance company deciding when I'm ready to die.
That said, I agree with everyone that DNRs are often not used appropriately, and doctors need to take a stand and refuse to treat beyond a certain point. Families also need to be educated about hospice. Most think that hospice itself is a death sentence. I think the opinion would be different if the public was educated that hospice is really dedicated to enhancing the QUALITY of NATURAL life for as long as the person has it.
people need to take more responsibility for their health. they need to quit smoking, lose weight, eat more healthfully, and improve their stress levels.
if you smoke you have a higher risk of heart disease and other health problems, yet you want people to provide you with free health care??
our health care is so expensive for a variety of reasons, one of which involves the way we treat our bodies. another problem is malpractice, law suits, which definitely drive up costs.
there are so many issues that need to be dealt with...
We need to remove the power to make these decisions from only the family. We have to get ethics personnel involved, and maybe over ride their unrealiztic desires at times.
I think we do too much. Most of my experience is in LTC and at the point that you can't survive without 24/7 nursing care maybe it's time to drop some medications and bladder retraining programs and concentrate on a good few last weeks. And when a baby is born with no GI tract etc. let it go.
We're just not willing to let anyone go for any reasons.
Not_A_Hat_Person, RN
2,900 Posts
Is this because, as one man said "They can go to the emergency room" ?