Saturday, December 26, 2009

Living Forever.

Last week, the New York Times continued their series on end of life decisions, Months to Live, with a dissection of the commonly used Dartmouth stats regarding end of life costs. The UCLA medical center has refuted the Dartmouth study and done their own, saying that they prefer to do everything necessary to prolong life, or death. Fran Johns at True/Slant takes issue with the article and the UCLA premise that can life forever:

Why is this not an encouraging word? In a front page article, part of a Months to Live series, New York Times writer Reed Abelsonleads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die. Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We couldtalk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.


And to continue the "life forever" thread, you can catch my favorite impractical blogger, Wesley J. Smith, on the same issue here. Of course Smith doesn't believe in global warming either.

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Catholic Right and Catholic Left.

In what many are characterizing as a break with the Catholic Right (read US Conference of Catholic Bishops) the Catholic Health Association, with the nuns getting their back, have issued statements supporting the compromise included in Thursday's Senate health care bill, saying that unlike the more strict USCCB, they believe that the compromise does enough to honor the principle of the Hyde Amendment which bars use of federal funds for abortion.

From the New York Times:

In an apparent split with Roman Catholic bishops over the abortion-financing provisions of the proposed health care overhaul, the nation’s Catholic hospitals have signaled that they back the Senate’s compromise on the issue, raising hopes of breaking an impasse in Congress and stirring controversy within the church.

The Senate bill, approved Thursday morning, allows any state to bar the use of federal subsidies for insurance plans that cover abortion and requires insurers in other states to divide subsidy money into separate accounts so that only dollars from private premiums would be used to pay for abortions.

Just days before the bill passed, the Catholic Health Association, which represents hundreds of Catholic hospitals across the country, said in a statement that it was “encouraged” and “increasingly confident” that such a compromise “can achieve the objective of no federal funding for abortion.” An umbrella group for nuns followed its lead.

The same day, the United States Conference of Catholic Bishops called the proposed compromise “morally unacceptable.”

The divide frames one of the most contentious issues facing House and Senate negotiators as they try to produce a bill that can pass in both chambers.

For months, the bishops have driven a lobbying campaign to bar anyone who receives insurance subsidies under the proposed overhaul from using them to buy coverage that included abortion. Citing the bishops, a group of House Democrats forced their liberal party leaders to adopt such a provision and threatened to block any final legislation that fell short of it. Abortion rights supporters, in response, have vowed to block any bill that includes such a measure.

Officials of the Catholic hospitals’ group and the nuns’ Leadership Conference of Women Religious declined to comment.

Catholic scholars say their statement reflects a different application of church teachings against “cooperation with evil,” a calculus that the legislation offers a way to extend health insurance to millions of Americans. For the Catholic hospitals, that it is both a moral and financial imperative, since like other hospitals they stand to gain from reducing the number of uninsured patients.

And in practical political terms, some Democrats — including some opponents of abortion rights — say that the Catholic hospitals’ relative openness to a compromise could play a pivotal role by providing political cover for Democrats who oppose abortion to support the health bill. Democrats and liberal groups quickly disseminated the association’s endorsement along with others from the nuns’ group, other Catholics and evangelicals.

“I think it is a sign that progress is being made, that we are getting there,” said Representative Steve Driehaus of Ohio, one of the Democrats who forced the House to adopt the stricter restrictions in its bill. The hospitals’ statement, he said, recognized the Senate’s compromise as a meaningful step, making him “optimistic” that Democrats could find a bill that he and other abortion foes could support.

Other abortion opponents argue that liberals are overstating the hospital association’s influence. “They don’t carry the same sway,” said Representative Bart Stupak, the Michigan Democrat who led the effort that resulted in the House bill’s including a full ban on abortion coverage in any subsidized health insurance plan.

Mr. Stupak said he still had commitments from at least 10 Democrats who voted for the House bill and pledged to vote against the final legislation if it loosened the abortion restrictions — enough to keep the bill from being approved. “At the end of the day we are going to have something along the lines of my language,” he said. Abortion rights supporters said the signs of openness from Catholic groups were helping some Democratic abortion foes accept the Senate compromise.

“We have known for quite some time that the Catholic hospitals and also the nuns are really breaking from these hard-line bishops and saying, ‘This really is our goal: to get more people into health care coverage,’ ” said Representative Diana DeGette, Democrat of Colorado.

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