I'm not proposing rationing or coercion. I don't want to make decisions for pts or families. What I DO want is someone objective, to honestly and compassionately provide hard truths about what death and dying looks like.
Doctors, for the most part, are not objective. Some I work with want to keep the pt alive as long as possible because it means a paying customer. End of life is when most of the health care dollars are spent, and that's where MDs and hospitals make the most money.
Death panel? Call it what you want, but our society is sorely lacking in honest accepting discourse about death.
Some people want to live forever and will submit themselves to any test, drug or procedure for that end. I respect that decision.
Some people want to live as long as possible, with quality of life determining how much intervention they want.
Shouldn't these people be given hard, basic information to guide them in these decisions?
Physicians seem to be in the biggest denial. 89 yrs old, CA with mets, life expectancy is nil, but we force the person back to life after a normal physiological process, and make them die over and over, as if they were a toy. Where's the compassion in that? Not to mention the logic?
My children know that, if I'm terminal, they had best not make me die repeatedly, or I will haunt them and all my caregivers to the ends of their lives.
AMEN!! My thoughts exactly! Dad said the same thing about haunting us . I don't know that MDs hold the all the cards on denial, I've seen a few nurses who do too. We rotate docs every month, and some months when particular attendings are on...we know it's going to be a long month and end of life discussions are going to be few and far between.
Specializes in Spinal Cord injuries, Emergency+EMS.
I don't feel it's the government's job to regulate when/if/how we have those conversations, and to be encouraging it to perfectly healthy people.
Just my $0.02
why would you be having an end of life discussion with a healthy person ? - there's only one scenario where that routinely happens and that's for someone with a life long condition which is known to have an adverse effect on life expectancy ... and the escalation plan should be part of the routine discussion between between this expert patient and the team responsible for their ongoing care and yes it will mean hard questions sometimes such as at what point in the disease process does it become futile to invasively ventilate someone with a degenerative lung condition if they get an exacerbation or severe infection on top of their existing problems - bearing in mind the risks of ventilation such as further infections ,ARDS etc as well as the difficulties in weaning someone with clapped out lungs.
who other than the back pockets of hospital and LTC owners does it serve to have people who are long term unweanable vent patients especially if their quality of life is not what they might want it to be ....
adding years to life is not necessarily the aim of healthcare unless you can add life to those years.
the Fundamanetal Problem the US faces is the fact that Healthcare Professionals are unable or unwilling to draw a 'line in the sand' in terms of futility for radical treatment vs palliation...
Specializes in Spinal Cord injuries, Emergency+EMS.
You've got it right!! The cynics who coined the term "death panel" ( Tea Party/Sarah Palin/Glenn Beck et al) were only trying to create hysteria and panic as they lobbied against health care reform.
it's classic USAn right 'reds under the beds ' hyperbole
at the end of the day who would you rather decide treatment priorities Clinicians and scientists on the basis of the evidence base or the insurers and hospital owners on what is more profitable ...
Specializes in Spinal Cord injuries, Emergency+EMS.
My mother is nearly 90 but is healthy, active and lives on her own. She is absolutely convinced as are many older people that when Obamacare (her word not mine) comes to fruition health care for the elderly will be rationed.
despite the evidence from 'socialised health care' nations where clinical outcomes are the determinant of treatment options rather than arbitrary age cut offs.
Specializes in Spinal Cord injuries, Emergency+EMS.
I just think the government needs to say out........I look at many government run entities ......I am NOT impressed! If they really worked for me......I'd be having a massive firing!
I thimk the term death panels liken more to WWII and Hitler......hence the extreme unease.
which is exactly what the McCarthyites who support the Status Quo want rather the 'evil' , 'reds under the hospital beds' that 'communist healthcare' brings ...
why would you be having an end of life discussion with a healthy person ?
why should you have a end of life discussion with a healthy person? because not all people that that die are sick/terminal before they do. many people that are in icu and unable to at that point to state their wishes, were heathy just prior to what brought them there. traumatic illnesses or accidents can and do happen to healthy people, even young people. and without knowing what a person wants, health care does have to take the side of life.
a person could have wanted to be let to die if in a situation and then have family fighting to keep them on support.
look up a woman name terri schiavo...was 27 and healthy prior to a cardiac arrest ....and then kept alive for 15 years. 8 of those years family fought to keep her alive, and husband wanted to let her go. had she had a living will stating do not keep me alive under these circumstances, her desires would have been known.
look up nancy cruzan.....25, healthy, and had a car accident....on support for 7 years. 3 of which her family (all of her family) fought to take her off support, that she wouldnt not want to live like that, but they had no proof.
look up karen ann quinlin...21, stopped breathing after taking drugs. family had to fight to get her taken off support.
nancy cruzan and karen ann quinlin are the 2 cases that established the need to have written advanced directives. not elderly sick/terminal patients.
This may sound a little extreme, but since car accidents can be deadly, perhaps a living will should coincide with obtaining a driver's license at the age of 18. (Parents can decide until that age)
This may sound a little extreme, but since car accidents can be deadly, perhaps a living will should coincide with obtaining a driver's license at the age of 18. (Parents can decide until that age)
I would agree with that. A Dr could discuss it with them and their parents if they wished to include their parents when they go to get the physical that is required for a drivers licsense. Though it should be periodicly be updated as the individual matures and has a fuller understanding of things, and beliefs change. (so probably every few years between then and late 20s early 30s......have to remeber late teens/early 20s one is still in a "nothing is going to happen to me" stage....that mindset is probably the main flaw in advanced directive at that age, but even just giving POA to a person they would trust would be better then nothing at all, would at least give parent that has that POA more ground to stand on in deciding an adult childes care in that position)
Right now it is required to ask when going into hospital for a procedure but conversation probably 99% of time goes like this Dr - "Do you have a living will" Patient- "No" Dr- "Would you like to discuss one" Patient -"No", and then not another word said. It should be more regular to discuss it with a patient, and the Dr should be going this is what a living will is, this is why it is important. Drs should be trying more to push patients to think about what they would want (as well as educate them on their choices) and to understand why it is important to have it in writing. I think that is what the law is trying to get started. If drs are being paid for that individual time to have that discussion, it may become more likely they will have a full discussion, not just something brushed off with a no and then move on. Its the wrong motivation, but it is a movement in the right direction.
Discussing end of life care is NOT just about "do you want to treat this illness even though treatment likely wont help, or just treat pain and let it take its course"......its about, if you are in a possition that you are unable to state your desires, to what extent do you want Drs to go to to keep you alive. At what point would you want them to let you just die.
why should you have a end of life discussion with a healthy person? because not all people that that die are sick/terminal before they do. many people that are in icu and unable to at that point to state their wishes, were heathy just prior to what brought them there. traumatic illnesses or accidents can and do happen to healthy people, even young people. and without knowing what a person wants, health care does have to take the side of life.
a person could have wanted to be let to die if in a situation and then have family fighting to keep them on support.
look up a woman name terri schiavo...was 27 and healthy prior to a cardiac arrest ....and then kept alive for 15 years. 8 of those years family fought to keep her alive, and husband wanted to let her go. had she had a living will stating do not keep me alive under these circumstances, her desires would have been known.
look up nancy cruzan.....25, healthy, and had a car accident....on support for 7 years. 3 of which her family (all of her family) fought to take her off support, that she wouldnt not want to live like that, but they had no proof.
look up karen ann quinlin...21, stopped breathing after taking drugs. family had to fight to get her taken off support.
nancy cruzan and karen ann quinlin are the 2 cases that established the need to have written advanced directives. not elderly sick/terminal patients.
exactly. when a person is healthy is the most important time to discuss it! i've had the talk with my mom, about both of us. at the very least, everyone should have a living will and an advanced directive, and it should be done before they get ill. you never know when you will suddenly be unable to make your own choices (such as the result of an accident). they can be redone if your wishes at any point change, they're not set in stone ("too late, you already said this, so now you're stuck with it"). end of life discussions are not just for the chronically ill or elderly.
I would agree with that. A Dr could discuss it with them and their parents if they wished to include their parents when they go to get the physical that is required for a drivers licsense. .
Just curious - where do you live? Because in California, you do not have to get a physical before getting your driver's license.
I don't feel it's the government's job to regulate when/if/how we have those conversations, and to be encouraging it to perfectly healthy people.
Just my $0.02
Each of my children (all adults) has Advanced Directives and designated POA for healthcare. End of life issues should not be limited to the elderly, each of us takes our lives in our hands on the way to and from work. During my hospital years, I have seen many nasty situations involving a young trauma victim and family members who made the situation so much worse by fighting and arguing. Advanced directives does not mean that you do not want lifesaving measures under such circumstances, but everyone should make their wished known. I would rather my children make the decision for themselves so I don't have to make it for them.
The only proposal was that an appointment to discuss this issue became a reimbursable item, like a follow-up or another such appointment, with official codes et al. These discussions take time, and slots are already pared down to the minimal quarter hour or so. Having it be "official" would make it done better and more often. That's not government regulating if/when; that's Medicare reimbursing for it....
I am a Case Manager and have discussed this issue with a lot of my patients. I am surprised to find that many have already discussed with their physicians. You are correct, the bruhaha was all about reimbursement. The actual counseling has been going on for years.
blueheaven
832 Posts
AMEN!! My thoughts exactly! Dad said the same thing about haunting us
. I don't know that MDs hold the all the cards on denial, I've seen a few nurses who do too. We rotate docs every month, and some months when particular attendings are on...we know it's going to be a long month and end of life discussions are going to be few and far between. 