Medicine: Have we gone too far? And, is our system ethical as a whole?

[GardenDove]

Sometimes I disagree with some of the things that I do in my job. I'm sure we've all felt this, such as a 95 year old full code on a vent, or other such scenarios.

Personally, I feel like medicine often goes too far, especially in prolonging end of life. People view it as their salvation from death, in almost a religious way. Meanwhile, some people don't even have access to clinic care because of their lack of insurence.

Medicine will spend 1 million + for organ transplants to save one life, then some clerk at 7/11 can't even be followed by a primary doc because they don't have insurence.

I had a pt last night, a man on his last leg, who should have been a no code, but we're spending a small fortune on him. As a side note, he brought his health problems on himself entirely due to his terrible health habits. How about drug and ETOH addicts that then cry out for liver transplants! Where's the justice in that while some kid in South America just needs clean water?

[nursemike, ASN, RN]

As far as someone's right to drain the healthcare system because they are in denial about death, isn't there some sort of communal responsiblity here? Do we have a right to a million dollars in futile care just because we're scared to die? What about the basics for everyone? That's where I think our system is out of whack. We don't have infinate resources, as much as we would like to pretend.

I think I can see your point, but I strongly suspect it's a bit off the mark. As expensive as heroic measures can be, I don't think these million-- and multi-million dollar cases as common enough to be a major drain on the system. I think it's more often the thousand and tens-of-thousand dollar cases that could have been avoided with hundreds of dollars of prevention.

A few years ago, there was a patient at my facility whom, in one of my more morbid moments, I called "the human Medicare check." This was before I was a nurse (if that's any excuse). This poor fellow was very old--late 80's, I think, and old for his age. He was diabetic, with both lower extremities amputated, but every couple of months he'd be back to whittle off a little more or treat a stage IV decub or whatever, then back to LTC. I don't think I ever saw him in double digits on the GCS. Not much of what any of us would call quality of life.

I don't think there was any intent to defraud Medicare. Each intervention did ward off a life-threatening crisis, but none was going to cure him. I believe he was a no-code by the time he passed, but I don't know for how long. I don't think of removing a gangrenous extremity as a particularly heroic measure, nor does letting him go septic and die seem especially humane. Yet, clearly, it would have been very much in his best interests and those of society if he could have been adequately treated before he reached that state.

My father, who is diabetic, gets pretty decent care through our facility, funded primarily by his Medicare. I don't feel he is being let down by the system, although he is burdened by an unfortunate amount of debt for co-payments and deductibles. Reluctance to add to that debt is a bit of a hindrance to compliance with care: he doesn't want to "run up doctor bills when nothing's wrong" with him. Makes me wonder whether the patient I spoke of might have felt the same way, with no family to tell him to screw the co-payment, they're happy to get the Medicare.

Hilary was right, a decade ago. We do desperately need health care reform for millions of uninsured and underinsured Americans. (I share the concern of many that when such reform comes, it will be an even bigger mess than it is. Part of the problem, as I see it, is that Congress is usually so worried that some may get benefits such as welfare or medical care who don't need them that they make it needlessly difficult for those who do need them, and meanwhile, there are still plenty of less deserving recipients who figure out how to work the system. College students get food stamps while people who are hungry can't adequately document that they haven't eaten in three days.)

Anyway, I think that's a bigger, and costlier, problem than liver transplants and ventilators. JMHO.

[medsurgnurse, RN]

:yeahthat:

I think a course and maybe even a clinical rotation in palliative care needs to be to be mandatory for nursing and medical school.

That's not a bad idea. We have to rotate through other specialties why not palliative care. When I start doing hospice nursing I had to reprogram my "nurse thinking." But I have never been asked to end a life and would not participate if asked. I do believe in adequate pain control.

[medsurgnurse, RN]

I am not trying to speak for the OP, but I would like to voice my opinion on this issue: I don't believe that those without private insurance should receive inferior quality healthcare, but nor do I believe that those who receive healthcare courtesy of the taxpayers should get benefits SUPERIOR to those of us who work to pay for ours and theirs.

I lived in PA a number of years ago, at a time when recipients of taxpayer funded healthcare received comprehensive medical, dental, prescription, and vision benefits. Both my husband and I were gainfully employed, paid substantial premiums thru payroll deduction, and neither of us had dental or vision insurance. We also had to meet deductibles before our coverage "kicked in", and were limited in our choice of providers, while those covered (at no personal expense) by publicly funded plans had benefits far superior to ours with no financial obligations.

That is not right, either.

you're right.

[KellieNurse06]

-

- When working Labor & Delivery and Mother/Baby, I realized there were more patients there on Medicare than private insurance. The ones with Medicare got the same treatment, including all the freebies as anyone else. Who pays for all this? Taxpayers. These were people who fully able to work but refused so they could get free housing, free medical care, free groceries, etc and not have to leave home to work for it.

Does it really matter????? Come on!!!! Regardless of what insurance anyone has should be irrelevant! Everyone should get the same medical care regardless if they medicare, medicaid, blue cross, harvard pilgrim.....whatever....There are people who fall on that line of making too much to get help but yet don't make enough to pay for insurance.......Come on I think you are stereotyping here.............Honestly who "really" wants to be on any type of public assistance really????? And God forbid if you or a loved one should ever become totally disabled.....and need to go on..*** ****** medicare/medicaid.......then I bet you'd have a change of heart real quick ...it's easy to judge when it isn't you.......so please don't say people are fully able to work but "refuse" to because you don't know that for certainty...... :chair:

[StrwbryblndRN]

Everyone who posted previously has made wonderful points regarding health care. We are preaching to choir. Our profession allows us to be up to date on health care and the benefits of prevention. Unfortunately society does not have the full spectrum of information. They may have the resources but may not accept it. Or they take advantage of the resource and use it inappropriately

It has been drilled in my head since my very first semester of nursing that "education starts at admission". I hope to see the same concept applied to our health care. The minute someone makes use of health care, that person should be educated about what is available and what they can do to maintain their own health. There is alot I could have learned if I knew what to even look for. Alot people do not even know to ask.

I do not wish to see people not make use of health care in fear they will be rejected or condemned. But hope that people can educate themselves with information to make more informed decisions. (that applies to all aspects of life)

am i asking too much?

[GardenDove]

There are, actually, some people who are permanantly dependent on public assistance, and do know the system inside and out. You can't project your own middle class standards on everyone and assume that everyone shares your desire to contribute and be productive. Yes, sadly, a certain segment of the population is not able to function within the framework of modern society and will seek to exploit the generosity of the social welfare system.

[StrwbryblndRN]

In regards to insurance. I went from the best insurance coverage to none for my family of 4. (Husband lost job, you can guess the rest)

It bothered me to think that medical staff (doctors/nurses etc) would feel such contempt for my lack of coverage. (I noticed my peds office not as receptive as they once were when my children were sick)

Yes it makes me mad to see anyone go to ER for stupid stuff. Yet who are we to judge. I do not work in a hospital currently so I do not see what everyone else sees. But I was on the other end of it. Besides as a nurse, I thought that informatin regarding coverage was handled through other means. Not by the nurses that treat you.

Granted on a large scale it is draining our health care system but as a care provider I hope to do my job and not let it affect the quality of care I give. I know most of you do not do that but be very aware of any attitude you may give off. I noticed it quite a bit as a patient/parent of patient.

[Cattitude]

and part of the reason for high premiums is to pay for the last ditch, and often futile efforts, to save the life of a person who hasn't come to terms with his/her situation. since i've worked in the icu the past year, it's really driven this fact home to me how much we, as a healthcare community, spends on these heroic attempts to reverse the irreversable.

i remember a guy we had in sicu for over a year. he was intubated but awake and alert for about 6 months of that time. he just could never quite get to that point to come off the vent. anyway, he was miserable. through the course of thar year, i got to know him pretty well and we got to chatting one night. i asked him did he want to go on like thi. he shook his head no very fast. and did it again. apparently, i wasn't the only nurse who had asked him this.

alas, his health care proxy did not respect his wishes when he was first brought in, he should never have been intubated in the first place. finally, going into the second year he died...

[Agnus]

The reason, though, that people don't address it is fear. People are afraid of death, pure and simple. Even devout religious people are.

Interesting. I had someone ask me last week. "If we believe we will go to heaven, why do we fear death?"

It is of course within every living organism the inate "need" and there fore struggle to survive. Reproduction is linked to this survival response.

[Agnus]

In regards to insurance. I went from the best insurance coverage to none for my family of 4. (Husband lost job, you can guess the rest)

It bothered me to think that medical staff (doctors/nurses etc) would feel such contempt for my lack of coverage. (I noticed my peds office not as receptive as they once were when my children were sick)

Yes it makes me mad to see anyone go to ER for stupid stuff. Yet who are we to judge. I do not work in a hospital currently so I do not see what everyone else sees. But I was on the other end of it. Besides as a nurse, I thought that informatin regarding coverage was handled through other means. Not by the nurses that treat you.

Granted on a large scale it is draining our health care system but as a care provider I hope to do my job and not let it affect the quality of care I give. I know most of you do not do that but be very aware of any attitude you may give off. I noticed it quite a bit as a patient/parent of patient.

Quite true. There is an attitude. AND it is not the exclusive doamin of the billing office to deal with this. Doctors and Nurses are underpressure to limit services and there fore expense extended to patients where we know no or very little of the money will ever be recovered.

We tell ourselves even in this age that is not my domain. But the reality is the pressure is there. It is our domain.

Back in 1962 my mother was admitted to Will Rogers Memorial Hospital in Saranac Lake NY. That hospital has since closed. But it forever has influenced my values about health care. We were never allowed to pay a single penny for her 3 month confinement and frequent returns as an out patient. They did not even make a claim on her medical insurance. She had a private room and what today would be considered extreem luxuries beyond what you can imagine. These were in the form of therapies that addressed the whole person. Today we would not even consider them but are just as valid as effective theapies. Wil Rogers saved my mother's life.

They had a rule she had to have been completley discharged for a full year (I think I recall that is the correct time period) before they would accept a donation from anyone in our family. As long as she was a patient there they refused any money in any form from our family.

I remember when in the 80's I lived in West Germany and my landlady told us that when she was in the hospital they refused money from her. That is how their national health care insurance worked. She tried to give them money as thanks and they refused. She wanted to do this because of the high quality of holistic care she received and they would not take it.

[psalm_55]

ACCESS to health care is unethical.

i believe the USA is the only industrialized nation without universal access to health care.

many of us have children who are 23 y.o. and kicked off the insuramce role. they/we must forage for affordable health insurance coverage and self-pay.

if they are without insurance and need an expensive diagnostic test such as an mri, it's cash up front -- or no mri. and the average ER visit is about a thousand dollars.

at the other end of the spectrum -- look how many 70 and 80 year olds (and older)are on cholesterol-lowering drugs. WHY???

given the cost (which is being transferred to taxpayers now) and the age, haven't these drugs ALREADY done what was intended?

they lower cholesterol in order to prevent a cardiovascular event. their effectiveness is measured in DECADES. so, one who starts on these drugs will see the actual intended effect about 10 years down the road.

i don't get it.

[prowlingMA]

i totally agree. i have worked in ltc and seen miserable pt given life sustaining treatment when all they really wanting was to be free of pain and suffering and be in peace.

it comes down to some people are afraid to die, plain and simple. if i am in pain and unable to breath, eat , or live without machines, let me go.

living isn't having a life.

then you could also bring up the topic that some couple go through million dollars worth of treatment to produce a baby when there are thousands of kids in the foster care system that need a good home. they may not be perfect blond haired blue eyed infants ( but who of us is perfect).