Is this cruel and cowardly? An end of life issues

Great Debates
41

There’s two different things meant by “medical care” in terminal situations. There’s treatment – efforts to cure or solve the problem, and there’s merely keeping the patient comfortable until the end. These are VERY different approaches.

Hospice is basically a means of not trying to “cure” the disease, but making sure the patient has no discomfort. Hospice is covered (and highly regulated) by Medicare and Medicaid.

Generalization: people who think that patients should always be treated have never had experience with loved ones suffering debilitating disease. There’s a big difference between what Fear Itself’s wife is facing (my full sympathies go out to you), and my father-in-law, aged 93 with Alzheimer’s, incontinence, COPD, and a host of other problems. If he gets pneumonia again, we’re not going to subject him to “treatment” that will prolong non-life.

42

27 - 30% of Medicare payments are during the last year of a patient’s life. Cite and I’ve got more from pub med, such as this one. That doesn’t say how much is spent on acute terminal care, but I think it is reasonable to estimate that the cost is clustered around the end.

Since this is Medicare, you can’t blame for-profit insurance companies for anything.
Besides directives, I don’t know how to deal with this. Unless you have an instrument like the one in Heinlein’s “Lifeline” you don’t know it is the last year of life until it is too late. I doubt the profit motive has a lot to do with it. Doctors are trained to save lives, and I suspect that is the cause far more than making their hospital money.

43

Years ago, I would have agreed with this. After conversations with many doctors over the last two years, I now think it has more to do with fear of wrongful death lawsuits. Unless the patient has made it exceedingly clear, in writing, what they don’t want done, the doctor’s always faced with the worry of not treating aggressively enough and facing a deposition. There, she’s going to be asked very specifically why she didn’t do X, Y or Z, by some lawyer hired by the family because they’re angry and grieving that Grandma died and want someone to take the blame for that.

Even if you win the suit, there’s the headache and heartache of the deposition (no one likes having their medical judgement called into question, and we all feel bad even when we know there was no other good option), lost hours where you’d rather be practicing medicine than sit in a courtroom, not to mention the risk of your malpractice insurance premiums shooting sky high if you attract lots of lawsuits - even if you win them.

44

The problem is, it’s almost never clear-cut. I lost a friend to cancer. She was relatively young, active, alert. The only problem was that none of the treatments worked. In retrospect, every dollar she spent on treatment was wasted. But no one would have predicted that when she was first diagnosed. So where should the line have been drawn - after the first round of chemo failed, the second, or the third? She herself drew the line when the third round failed, and died only a few weeks later, but there was still another treatment the doctors were ready to try on her. Did she give up too early, or too late?

45

Isn’t end of life care a huge part of the Medicare budget? Like, the last six months of someone’s life is supposed to be most expensive, right?

Why do we do that? What good does that do society? I would be OK if “terminal” meant “terminal”. As in, it is time for you to die now - within a reasonable time, you know, like, your cancer is terminal, we will stop paying for non-essential care after 1 month and after that we make you comfortable. Or something.

46

The thing to consider, though, is that “terminal” isn’t a decree or even a diagnosis, it’s a guess. An educated one, true, based on how long other people with similar conditions have lived, but still a guess for each particular patient. Some people (one already mentioned in this thread; my grandfather was another) get a terminal diagnosis and live pretty well for another 5 years. If you get a cold during that 5 years - and the cold isn’t likely to kill you - should we let you have some Theraflu or Sudafed? What if it’s pneumonia? Should we give you the antibiotics to treat it? What if the pneumonia is bad enough that you need some help breathing with a ventilator, but we expect we’ll be able to wean you off it in a few days and then you’ll recover from the pneumonia? You’ll still have your terminal diagnosis, but you might have a few more years of decent life in you.

These are the kinds of decisions people are faced with. And this is why Advanced Directives need to be very specific. While it’s true that many of us don’t want to be kept alive for a *prolonged *period of time on ventilator, it’s also true that many people get that pneumonia and just need a vent for two or three days for an acute problem. So a blanket “no treatment” or “no ventilators” decision may be easy to write on paper, but not really what people mean - they’re not thinking of a short duration for an acute infection, they’re thinking of long-term ventilation during a protracted, ultimately fatal decline.

The real trouble is that even people with terminal illnesses get acute infections that are not themselves lifethreatening and will resolve with treatment, and some of them would like them treated and some wouldn’t. Most people just aren’t sure what’s best (including the doctors and nurses), so you just muddle through the best you can.

47

Failure to diagnose is malpractice, failure to treat is malpractice. Malpractice insurance is the greatest cost for a doctor to practice medicine in the United States. (Well, for some debt maintenance on their school loans is still number one.) Doctors have to exhaustively test for any possible disease consistent with their patients symptoms. Those tests are necessary even if the doctor actually doesn’t think the diagnosis is likely. There are thousands of lawyers waiting to make millions on the outcome.

So, when you learn what the going rate on testing is, and you already know how difficult the actual test is, investing in the business of running those tests, which you will have to pay for over and over again is not milking the system to make millions, it’s minimizing the cost of fending off suits for damages, which your insurance company demands that you do.

Tris

48

Why not let people make their own decisions? If someone is dieing of cancer, shouldn’t it be up to them how they’re treated? If a dieing person thinks painkillers and making peace with a quick death is the way to go then jack em up. If that person thinks fighting the good fight is the way to go then give them the weapons to fight.

Our societies can afford it.

Also per:

Do you have a cite for this claim? Are you extrapolating from the costs of the most skilled professionals, or the median? Because by definition most people will get just above median skilled or less.

Even assuming that point anyone who isn’t a monstrous sociopath will find the cutoff point a hard one. Further I imagine it’s much easier to decided about a cut off point when you’re not currently in danger of crossing it.

Let’s say it is. If someone pays Medicare taxes all their working life, shouldn’t they be entitled to use its provided services as desired, even at the end of life?

49

In theory, I sort of agree with the OP, but there’s the damned slippery slope that keeps sliding. What about expanding your idea to age? Once a person reaches 100, lets say, no more medical care for you, only pain meds. After all, how long can a person expect to live and have a good quality of life after reaching age 100? And that person has already lived longer than the vast majority of people will. Why should we pay to give them even MORE years? Then let’s drop the age to 95, 90, then 85.

That proposal seems horrible to me, but it is much like the one proposed in the OP.

50

Such a death is not cowardly.

No, the government should not be spending that money.

Yes, I would want my own mother to be put out of her misery. My life too, if it comes to that.

Your coworkers are idiots.

51

But the government (well, medicare/medicaid) does in fact pay for most of it. About 27% of medicare’s budget is spent on a person’s last year of life. Its less with medicaid because medicaid covers more younger people.

52

We have been rationing health care since there was more demand for health care than there was health care resources available.

I see health care spending by the government much like I see government run public education. You supply a minimum threshhold of education (or health care) that is available to all comers and you have to pay for that out of the economic activity created in the rest of the economy.

There are probably many children that would learn more and be better educated if they had a bunch of private tutors but we will bankrupt ourselves if we do that. So we pack 30 kids in a classroom (it approaches 100 kids in a classroom in many of the high achieving Asian countries and they frequently charge tuition even for public school) and say “good enough” If someone wants to send their kids to private school orn hire those tutors… fine but the government isn’t going to pay for it. The same should apply to medical care.

53

Then why is there a shortage of nurses? Why are doctors deciding to go into banking out of medical school?

54

If you knew that then why did you blame the medical profession?

55

Actually you can blame them. They take your premiums when you are young and healthy. Then when you enter a demographic that statistically suggests you may cost money, they dump you.
Medicare only gets that group. If we expanded it to include more people the cost of old peoples care would be spread across the ages and not be so crippling.

56

without derailing the thread, I’d like to give myself and American teachers a quick defense and say that in those countries, they don’t deal with the same crap. plus, places like Japan often employ a co-teaching model. :p:p

57

You are judging from the perspective of a young and healthy person.

Let me share something with you. I was a caregiver for several years for my stroke surviving, fully bedridden, mother in law. Now, prior to her stroke she had no difficulty standing in harsh judgment of her peers who, when the time came, chose to move in with willing children. She insisted loudly and often that is what not for her, that she thought it was wrong, a mistake. She was pretty firm.

After her stroke, well, suddenly she felt differently. Sure, you may say, “But I won’t!”, don’t be so sure, is all I’m saying.

That’s not the end of my story. After 6 yrs her health took a turn for the worse. We all knew we weren’t going to put her back in hospital, we all wanted a home death, with dignity and loved ones surrounding her. No heroic efforts, no resuscitation, etc. When the Dr came in to see her, he told us, “It won’t be long now!”

We were living in a newly ratcheted up world now, waiting for the inevitable. It was horrible listening to her shallow breathing etc.

Ten weeks later, she died. Ten weeks. I am convinced death should never be rushed. For all of everyone’s predicting, she wasn’t ready to go. She couldn’t talk by the end, but I was convinced she wasn’t going to die until she’d finished doing her emotional work in this world. And apparently that took ten weeks. Personally I think there is a possibility that your moment of greatest clarity might be on your death bed.

Often times they remove people from life support and prep the family thinking they will surely die almost directly. But sometimes, that’s not what happens, sometimes they hang on for days or even weeks. I say don’t rush them.

58

Humane to put down suffering pets.

Monstrous to not go to heroic lengths to give someone in horrific pain another five minutes.

We have great priorities.

59

Devil’s advocate here - The Advanced Directive that one might put together as a healthy 40 year old may be quite different than the one someone puts together when they are 80 year old and not doing as well.

Since the Advanced Directive will be unreliable, depending on a whole lot of factors (age, mindset, health, finiancial situation when written, etc) maybe you should err on the side of caution when this topic comes up.

When I was in college I had a traumatic incident where I lost some front teeth, I remember telling my GF (now wife) as an overly dramatic 20-something that I wouldn’t want to go thru that trauma again and that I would not want the agony of seeing myself like that again. If I wrote my Advanced Directive at that point, it would be remarkably different than the one I’d write today.

60

Going back to the OP directly, LonesomePolecat was surprised that everyone in the room came down on the same side of the argument.

I just wanted to point out that peer pressure, groupthink, whatever you want to call it, is particularly strong when it comes to moral issues.
When the first person showed moral indignation, it made your POV look like a dangerous one to hold. Supporting you would put one at risk of ostracization.

The next person feels the need to quickly find a flaw in your reasoning, rather than to soberly evaluate what you were saying.

But I would disagree too. An advanced society should aim to treat everyone that can be treated. We should be ashamed if we ever have to turn off machines to save money.

The interesting grey area though, is where there are drugs which cost thousands of dollars and which can only extend someone’s life by weeks, if that. In these cases…I don’t think there’s a single, easy answer.

Finally, “putting patients down” – with the patient’s consent, giving them some happy pills and letting them die peacefully – is something I’ve heard anecdotally happens quite often to patients right at the end. I think this should be brought out in the open and, generally, that euthanazia should be legal. I’d certainly want to go that way, rather than wringing out the last second of painful life.