Monday, November 23, 2009

The Cost of Dying: 60 Minutes Segment, A Must Watch.

Don't miss this fantastic 60 Minutes segment on how we die. It debunks ideas like forced rationing, elder desire for aggressive care, and the necessity of dying in hospitals. It's a great segment and I recommend your read the comments!

I'd have done some things differently.....for example:

Point made: Patients most often don't pay their medical bills out-of-pocket. In fact, they hardly look at their bill. My addendum: CBS should have provided actual price tags for costly EOL-in- ICU procedures, like CRRT, TPN, and
mechanical ventilation, as well as data to show the percentage of time these procedures are in place but do not prolong life.

Point made: Most people want to die at home or in hospice, but instead die in hospitals. My addendum: Discuss the fact that patients have a choice; that a living will is easy to complete, does not require a lawyer/fees (in most states), and that patients have a right to make their own healthcare decisions, especially at EOL.

Point made: Technology is available to prolong life. My addendum: despite this technology, a terminal disease is just that - terminal - and patients have the right to determine how and where they want to die.

Point made: Hospitals are incented to admit patients, and doctors are paid by the number of patients they treat. My addendum: State that terminally ill patients have a right to limit their treatments and days in the hospital, especially at EOL. I want insurance providers and Medicare to require terminally ill patients to prepare for EOL as a condition of treatment reimbursement.

Point Made: Dorothy Glas, RN, stated that her mother saw many (read: 25) consultants in her final hospital stay before her death. She and the CBS interviewer Kroft agreed these were basically CYA consults. My addendum: CBS missed a good opportunity to (1.) discuss how malpractice litigation has a direct effect on skyrocketing healthcare costs, and (2.) ask Dorothy Glas RN why she didn't question the attending MD about the many consults. Did Ms. Glas have good reason to believe the consults were necessary, or had the patient herself stated she wanted 'everything done', hence all the specialists? Did the patient have a living will? I can't stop myself from thinking that the referenced psych consult might have been most appropriate, considering there were 24 others. My bet is the
Palliative Care consult came last. Imagine the savings of money and complaints if PC had been consulted, say, within the first 6.

Point made: The $43,000 defibrillator implant in a 90-something year old. Dr. Byock referred to age and medical condition as reasons to question this procedure. My addendum: explore a patient's individual quality of life before we reference age. I've met a few robust 92 year olds that could run circles around a bunch of sedentary 72 year-old smokers. This was another missed opportunity;
Geriatric Medicine would have fit very nicely here.

Point made: Dr. Fisher stated the reason patients are admitted to hospitals is because it's the "path of least resistance" since physicians don't have time to treat these patients in their offices. My addendum to that would be"why are we discussing this?". Yes, hospitals get 'direct admits' from the MD offices, but don't the majority of ICU patients come in through the ED? Then again, I'm no Dartmouth researcher. This was valuable time wasted on a curious finding.

It's unfortunate that Mr. Kroft asked Dr.Byock the So Yesterday question about pulling the plug on Granny. Dr. B did a decent job of defending himself, albeit in a brusque sort of way. His intensity on camera is probably balanced by an endearing, sincere
bedside manner. Too bad CBS didn't interview one of the many patients who are undoubtably grateful for his interventions. I admire his passion.

I'm grateful to the CBS Fates for not airing the words 'Palliative Care' without a full explanation.....and there’s no telling what that explanation might have been ……phew...

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