Half of the deaths occuring could be delayed by medical means?

Factual Questions
21

Another TL;DR post.

As the boomers start their final massive increase in one business (death), this problem may get some resolution for the benefit to the gen X’ers.

The old “He’s dead, Jim” no longer is deemed proper.
In the US, we now have various definitions of death. “Brain death” is one criteria (and a quite controversial one).
The old “Heart stopping” (for X time is getting attention now).
The senior Bush prez is a classic - pneumonia - the inability to breath, even if brain and heart are still strong.

You can’t have this discussion without “You call this Living?” coming up. “Quality of life”.

If you want to hook up enough obscenely expensive machines, the pump can be kept going (or not - we now have portable, battery powered artificial hearts.
The respirator can replace the lung function.
Dialyzers can replace the kidneys

Saying “50% of all deaths can be delayed” is meaningless until you define “death” and “level of expense” “quality of life”.

Persistent Vegetative Condition is often cited as being past hope, and “No heroic intervention” is to be performed.

Does this discussion in France have anything to do with the introduction of “opt-out” for transplant organs?

22

Because it’s not necessary.

If the death in unexpected, unwitnessed, or under any sort of suspicious circumstances there will definitely be an autopsy done. That’s why my nephew, who laid down at the age of 24 for a nap and never got up, got a forensic autopsy. Which, by the way, revealed nothing. Best guess? He had an undiagnosed heart arrhythmia. Basically, instead of Sudden Infant Death Syndrome you’re looking at Sudden Adult Death Syndrome.

But when you have someone like my mother, with a 50 year history of heart disease who is declining in a manner consistent with heart failure why do an autopsy? To find out she died of heart failure? Wait - don’t we already know that?

Why don’t we investigate every CAR crash, then? Answer: too many and the cost of doing that is not one society wishes to bear. If there is some other evidence of wrong-doing a car crash is investigated, but not all of them, not routinely.

If there’s anything suspicious about a death we do, as a society, investigate but when a death is expected (as for the terminally ill) or pretty clear as to cause (gun shot to forehead, run over by train, skewered on a tree branch by a tornado, buried in an avalanche, etc.) why bother?

It’s about $3,000-5,000 to perform an autopsy, and it’s not covered by Medicare, Medicaid, or the vast majority of health insurances. Maybe most people don’t want to shell out that kind of money to find out that Aunt Sally, who had advanced breast cancer, died from breast cancer.

Define “appalling” and maybe I can answer that.

Also, context matters. My sister is a hospice director. ALL her patients die in a relatively short time period (except for that one still going 5 years later…) Is that a failure? You have to be terminal to get her as your doctor in first place.

23

My father was diagnosed with an aggressive lung cancer.

He went downhill very quickly and was dead in about 3 months.

A man I suspect, but do not know, was an employee of the “Home” came up to me and asked, in a somewhat anticipatory manner “Do you want an autopsy?”.

Another “expect strongly”: the “post” is a profit center for the “home”. And there are three other children who were milling about - I suspect he asked each of us the same "we didn’t make much on this one - let’s see if we can at least get somebody to pay us for a autopsy.

These people are not about sunshine and butterflies, or even a "gentle slip into the next life:

24

The medical industry is far behind aviation in the practice of system safety. They’re still largely in the cowboy & seat of the pants era we went through in the 1950s & 60s. With the same high level of avoidable serious errors we used to have.

I doubt that autopsies *per se *are the best way to detect avoidable medical errors of diagnosis, treatment, or practical patient support.

OTOH pretending nothing is systemically wrong and that the avoidable error rate is as close to zero as is cost-effectively possible is flat silly.

I do not believe for a moment the cynics’ argument that it’s due to the corporations (or nursing homes) profits increasing by harming patients. Ref my sig for more.
To the medical industry’s credit there is a gathering effort to turn the supertanker in the direction of reducing avoidable error. There are several systemic obstacles such as …

  1. The lack of an all-overseeing “FAA” for medicine.
  2. The industry being composed of hundreds of thousands of mom and pop shops instead of a dozen coast-to-coast behemoths. Most headed by folks who’ve absorbed the “doctor is infallible King” mentality.
  3. The 24/7 nature of hospital medical care requires patients be handed off to different providers every few hours.
  4. The extreme specialization requires serious medical care, whether hospital or chronic, be split amongst multiple specialists.
  5. The lack of a multiplier (all care is delivered essentially one on one by skilled = expensive people) means built-in costs are high.

None of this is about the complexity of biology and the fact that sometimes standard effective treatments don’t work on some people, and that sometimes viral meningitis looks exactly like ordinary cold or flu until the patient is past the point of no return. Those challenges will be with us always.

Population-scale medical care is vastly more complex than is population-scale aviation. So we shouldn’t expect system safety to deliver failure-free care. If we define failure as “patient dies”, then medicine will have a 100% failure rate … eventually. So that’s why “patient dies” is not the correct measure.

But we can and should measure “number of avoidable errors” both of omission and commission. Those are classes of failures we can reduce or eliminate, leaving the smaller harder core of failures beyond our state of the art to prevent.

Ultimately, this is bureaucracy and management, not medicine. Be aggressive about doing what we do in aviation: Don’t punish the error-maker except in egregious cases. Instead provide incentives, support, and means for error-makers to submit the situation to impartial data gatherers. Then, for errors that happen often enough or whose consequences are severe enough, regulators and industry groups will design the error opportunity out of the entire system insofar as is cost-effectively possible. Then train the workforce and enforce their compliance with the new improved standard. Any big operation with lots of people will have goofs. The goal is to avoid the ones we can, then detect and contain the rest before things spiral out of control.
Where aviation is today, we monitor all aspects of routine flights and collect statistical data on operations that are only a little ways away from dead center perfect. Perfection isn’t expected. But routinely operating 20% of the way from perfect towards screw-up is noticed.

E-medical records are a baby step towards that data gathering. Right now they’re far too fuzzy and undetailed an unstandardized to make much in the way of conclusions. They may be able to tell us there’s smoke, but they won’t point to the site of the fire.

25

Indigo …

Thank you LSLGuy for such clarity … there’s a balance here … and Broomstick makes some good points … but still, if health care actually cared, they’d do this on their own dime … like Volvo did way back when … sometimes we need to put good before money …

26

Looking at the posted article, I know I’m not upset about the" intensified use of opioids and/or benzodiazepines (28.1%)". If you have someone who is terminal and in pain, choosing to fight the pain is valid. I remember an article saying that the Catholic church did not object to such side effect shortening of life, provided that the primary purpose of the medication was to fight pain.

I say let the patient decide how much pain they can or care to endure.

27

Galvani dissected frogs, then found that frog’s legs would still twitch when given an electric spark. Were those frogs still alive? Their leg muscles certainly were.

Death isn’t a single point. Your leg muscles take a lot longer to die than your brain does. Your heart is a muscle, and takes a long time to die: sometimes it takes years to completely fail.

Time of death is always a deliberate professional opinion. Medical care is often not offered after time of death. It’s a related decision, but not exactly the same unless defined as such.

In some cultures, you * never ever * make a deliberate decision to end medical care. Rather, you allow medical care to end: in American hospitals you will find equipment that needs to be reset every [n] hours, which allows patients to complete dying if there is no further intervention, if their culture demands that approach.

28

Now you are just doing it on purpose. I know the feeling. I too am addicted to punctuation abuse. For me – it’s the emdash. I love it – too much Dickinson as a small child, I fear.

But help is out there! First you have to admit you have a problem-- can you do it-- friend?

29

Huh … I can quit anytime I want too … I don’t have a problem … it only “looks” obsessive … but it’s just the one puncturing mark … to it’s not compulsive … so I’m not sick or anything like that … stop looking at me like that …

30

It is obsessive. But it only rises to the level of a disorder if it causes you significant distress or dysfunction in your life. So you tell us . . .

As for the OP, well . . .

[sub]dammit, now I’m doing it[/sub]

90+% of patients will either get better or get worse no matter what I do. All I can do is maybe speed the healing or decrease the suffering along the way.

It’s that < 10% where I really want to make sure I’m paying attention, because sometimes a real meaningful difference can be made there. And by meaningful, I don’t mean extending life for a few more pain-filled and disabled months, but actually curing things and restoring function.

Sadly, most medical resources are spent on things that really don’t make much difference. :frowning: