It is a broken system - rant

[nutella]

Healthcare is more like a jungle as opposed to an orderly system.

The recent weeks I took care of many patients 90 + , quite few of them actually 95+.

I get that autonomy is viewed as the "highest good" and patients/families want to be "partners in their care" - but come on:

When you are 90 + years old frailty is real. It is not something that I make up. What are the chances that you are going to be ok if you get subjected to aggressive medical interventions including resuscitation with chest compressions and breathing tube?

Families do not live together anymore the way they used to.

And, family does not want to "get involved" much either. They work, have their own family or health problems, are not interested in getting involved. It is very frustrating.

In addition to the general "custodial care" problem, there is also no common sense.

ow can you be a "full code" when you are 90+ even though you might be in "good health" - whatever that sometimes means. It is crazy.

If you are in your 90s, your next of kin or surrogate decision maker may be also already i the 70s. I get patient-centered care and autonomy - a great concept - but the way it is carried out is really poor in my opinion.

People seem more unable than ever before to actually make decisions!

They get hung up on details that are non relevant in the bigger context, they do not understand all the implications, but also do not trust healthcare providers or put $$$ first.

The system is broken.

I encounter families and patients many times a week who need 24/7 help - custodial care - and who do not qualify for medicaid - they have assets or do not wish for medicaid to put a lien on a house. They also can not provide care to their aging parent and do not want to spend the money for long-term care. They bounce back and forth several times between hospital, rehab, and perhaps home for a day or few days. They are not rehab-able. Once they get close to the days allowed or approaching D/C and the family does not make plans to take the family member home, they rehab facility finds a reason to send them back to the ER - otherwise they get stuck with it.

When you are 90+, chances are there is always something wrong with you and admitted because everybody is afraid of ending in a law suit.

People hope that they "just die" in their sleep or while they are bouncing around - I hear that all the time. "when I get home this time, I just go to bed and die" - only that really does not happen anymore and not nowadays.

And why is it that we expect non medical professionals to make vital decisions that have huge impact on their health and quality of life. Last time I checked, resuscitation is still a medical "treatment" , which is the reason you need a physician order of you do not want that treatment in the community or hospital. So, logically, if this is a medical treatment - it should not even be offered if it harms more than it has benefits - "do not harm." But - it is approached in the disney-consumer style that does not make sense. Families do not want to make decisions that leaves them feel guilty.

I hear a lot "I cannot make that decision for my father - I do not want to kill him." The way it is approached is putting huge stress and burden onto families and patients.

The system is broken because primary care physicians who should have discussions and now also get reimbursed by medicare for advanced care planning still do not have discussions. They know that the patient will call 911 and once they start bouncing around "somebody" will have to address it. The lamest excuse I have heard recently is "it never came up - the patient was doing well" - when I said "really - there has not been a reason to discuss with the 98 y old patient and family that it is time to prepare for the future ???"

The acute care hospital was never set up to have those discussions and care planning on a routine basis. But that is what we do now all the time. And because it is not really our job to fix everybody's dysfunctional family life, dysfunctional dynamics, and we are not financial planners - we often just put a band-aid on.

What is it that Medicare and insurances do not get????

The problem is in the community but there are not much incentives or initiatives to fix it. Instead, the acute care place gets penalized for re-admissions or not paid for inappropriate admissions. But at the same time, medicare pays for the magic "short-term rehab" but only after a 3 day admission stay, which is often used by families to bounce a patient around at the EOL so they do not have to make any decisions or spend money on long-term care - in hope that the patient will "just die."

They do not get that you do not "just die" when you are in the system.

Yeah - the system is broken.

Stop bouncing people around at the end of life. Approach advanced care planning the right way and stop consumer disney style interactions that make no sense whatsoever.

[kbrn2002, ADN, RN]

Unfortunately, any attempt to change this situation immediately becomes a political football, AEB the mythical "death panels" of the ACA. I can just see the endless religious freedom arguments now.

So ... do readers think we should move more toward the British practice of DNR being decided by the attending physician?

It's hard to not see the value in an MD being able to make that decision when I see some of my residents families that are totally unrealistic about the prognosis for a decent quality of life for their loved ones. It's frustrating to see a person kept alive at all costs with zero chance of meaningful recovery. It's sad to watch a family that insists on prolonging the suffering that just won't change their minds despite all the education given to them.

[No Stars In My Eyes]

Becoming 68 next month, and in spite of being in reasonably good health, I am already starting my campaign to break down my PCP's resistance to even the IDEA of writing me a DNR order. I mention it at every appointment. I don't bore-in with a drill, I just mention it in passing, sometimes humorously, just to plant the seed.

I say that whoever dares to resuscitate me will be, from that point in time on, totally responsible for any and all medical bills. If I could get a writ from a lawyer or judge and it be legal, I'd do it.

If God sees fit to take me, I hope no one will try to argue with His plans.

[MunoRN, RN]

I am always surprised with how perplexed the family of a 95 year old can be with the idea that death is a real possibility at that age, but I haven't found age to be a particularly reliable predictor of how fixable someone is. I've had many patients in their 50's and 60's where pretty much any medical treatment is essentially useless, and many 80 and 90 year olds who really just need a quick tune-up.

I've found things like DNR status and withdrawing futile care seem to vary greatly based on region. I've worked in places where it's just sort of assumed that people should always die on a vent and with pressors on max, and I've worked places people are DNR most often because the medical futility and in general care is only continued when there is a clear potential benefit. What's surprised me most is that I've yet to come across a family member who was upset because care was withdrawn due to medical futility, they've always been more relieved than upset.

[Steffy44]

Depends on the 90 year old. I've taken care of some who could kick my butt (the exception). I've taken care of 60 year olds who looked like the crypt keeper. People are too afraid to make the hard call. I observed a code on an older lady and when they went to call the son he asked to think about what to do overnight. Don't you get it. We're beating on moms chest NOW! Just the other day I took care of a 90+ severely demented man...full code crypt keeper. Son is in total denial that he has dementia. Would not change the guys code status even though he'll most likely get pneumonia because he can't get out of bed post broken hip. Weighs all of 100 lbs. it's frustrating.