How do nations with socialized medicine decide who does or doesn’t get super expensive, heroic efforts in treatments? As an example in the US you often see stories about super preemies where the baby (if he or she lives) is likely to be severely health compromised all their lives, and yet staggering sums of dollars are spent individually on trying to save these babies. Does this happen in socialized nations?
Are some (more or less) brain dead people hooked up to heart lung machines in socialized nations, like they are in the US?
Canada may qualify as a “socialized medicine” country to you. I’ve never liked that term. I am paid well to work as an emerg doc and I personally think universal coverage is an obligation of government in wealthy countries. Rant ends. All my discussion applies to Canada as I have personal knowledge of same. I believe in England heroic treatments are often denied on the basis of age.
To answer your question, in Canada the patient’s personal power of attorney, spouse, family, public guardian (in roughly that order) will usually be asked by the doctor if they want heroic measures taken. Ideally, but not usually, this is done well in advance AND the patient’s decision is known at the time when it is actually needed. These questions would include things like do you want CPR if your heart stops beating, do you want to be intubated if you stop breathing, would you want a major operation or transfer to an ICU, etc. People in the medical community understand far better than the average person that there are good reasons to answer “no” to these questions for patient’s who are elderly, would be unlikely to survive these interventions, have lots of co-morbidities (other major health problems), etc.
The data backs this up – if you have a code in hospital (ER notwithstanding), survival rates at one year are quite poor – you were probably receiving maximal medical therapy and STILL had a major problem; and major problems cause other major problems. IIRC, a recent study showed some 70% of saved grossly premature babies have moderate brain damage. It’s easy to say do everything possible at the moment; but the consequences are a lot less pretty.
Patient’s wishes do NOT obligate the doctor to provide “futile” treatment. I personally think too much public money is wasted on heroic treatments. But they would be provided, up to a point, for anyone who wants one and has a reasonable chance of benefitting. There is certainly an age bias to these decisions – not unreasonably – since younger people tend to have fewer problems and are more able to handle complex and dangerous interventions.
I’m not sure you intended to imply this, but are resuscitation and intubation considered “heroic measures” in Canada? Wow. In the US, when we talk about heroic measures, we’re talking about procedures that are possibly unusual, difficult, expensive, with a low possibility of success. I now live in Japan, where they consider it heroic to do an X-Ray on your first office visit.
“DNR” instructions are commonplace in the USA, so there are many circumstances there where someone might not be resuscitated and such; I think there’s a terminology issue here.
One might define a “heroic measure” as one with little probability for success, or which costs a great deal, or which uses unproven technology, etc. What one uses would depend on one’s situation. My biases are showing.
Resuscitation and intubation are things I do routinely, in the nature of my job. Patients come into the emergency room in dire straits and I don’t necessarily know their name, wishes, co-morbidities, etc. So I usually try to resucitate them. The situation is different when it is a patient with a known diagnosis and history who runs into problems in the ICU – and one can better evaluate the chance of improving things. No one is saying CPR is expensive or resource-intensive, but it can still be highly inappropriate for some patients.
In Canada, “heroic measures” are routinely done on super premies. A recent study has shown that long-term outcomes are not so good. I doubt this will change things – people do everything they can for premies if their is a shot at survival, and defer thinking about quality of life.
The brain dead patient in the ICU hooked up to a heart-lung machine? Any ICU person can tell you stories of brain dead patients having a bed there for months and a family that refused to give up/face reality/deal with the situation/etc. I’m sure it happens less than in the States, but it certainly happens to a point, if the family wants it and the relevant doctor believes there is a chance for benefit.
To clarify, the more you know about the circumstances, the better idea you have whether even basic procedures will have a low probability of success (and might be thus, heroic). If you want another example, in patients who present to the ER with a ruptured aortic aneurysm (50% die, a further 50% die on the operating room table, which is 50km from my ER), we’d do everything we could for this patient, including flying them to the OR without a second though if that is what was wanted. (I’ve done this perhaps ten times with six survivors). Economics are NOT usually considered in dire circumstances by most doctors.
I may be misreading, or misunderstanding the metric measures here, but are you saying the operating room is 50 kilometers from the emergency room? Doesn’t that translate to 20+ miles? Are you in a remote facility that provides ER services but does not have an operating room?
For the record, I’ve always gotten good, quick treatment for my mild (but annoying) heart arrhythmia: EKGs, ultrasound, whatever.
What I didn’t get was good advice about the problem.
Medical care in Japan has many problems: a lack of privacy, grungy hospitals, and incompetent doctors. But I haven’t had a problem with waiting lists and all the kind of things that “socialized medicine” gets accused of in the US.
I work in a small town emergency room. Our hospital delivers babies, does C-sections, some gyne surgery, some general surgery (appendix, hernia), cataracts, dental surgery… we do not have a vascular surgeon, heart surgeon, orthopedic surgeon etc. and send these patients to bigger hospitals. With very sick patients, there is a provincial air ambulance helicopter service which is often unavailable, but helpful when it is. If the helicopter is busy, we call for a back-up doctor, stick the patient in an ambulance and drive down to a bigger centre with them.
