A patient asked me today what the difference was between dying and living the final month of her life in the hospital. It was a good question and got me thinking about a concept I have discussed with some of Boston's best palliative care experts during my residency and fellowship. The concept is one of prolonging death vs. ending life- and this is the single most important concept in the US healthcare system today, and one of the least discussed. Let me explain:
First, the facts:
1) Medical care at the end of life consumes 10-12% of the total health care budget and 27% of the Medicare budget.
2) 7-30% of total Medicare budget is spent in the last year of life
The Dartmouth Atlas Project published a few years ago studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. This study demonstrateed that even within this limited patient population, Medicare could have realized substantial savings—$40 billion or nearly one-third of what it spent for their care over the four years—if all U.S. hospitals practiced at the "high-quality/low-cost" standard. The study painted a picture of the health care system in disarray over the treatment of chronic illness.
Basically, there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:
--Both doctors and patients generally believe that more services—that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc.—produces better outcomes.
--Based on this assumption, the supply of resources—not the incidence of illness—drives utilization of the services.
In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
SO what does this ALL mean in english? Patents without living wills have thousands of dollars of healthcare expenditure in their final days, often regardless of their prior preferences as family members dictate their care, and little of this healthcare lends itself to a better quality of life, better outcomes,. So think about this: Would you rather, in your final days, with a debilitating condition, let nature takes its course, or have medicine prolong your death? If the answer is the former, time to sign a living will. No matter what your loved ones say, you'd be suprised how difficult it is, in the final hours of a family member's life on earth, to own responsibility for pulling back treatments, tubes, machines... and the living will takes all of the guilt and puts it squarely where it belongs: on the shoulders of the patient, years before they lost themselves to the inevitable.
Thursday, October 30, 2008
Wednesday, October 15, 2008
Cool
So I found this old piece I wrote last year in the middle of an overnight Emergency Room shift when things finally slowed down and it pertained to my last posting so why not continue a theme about addiction ;) Let me know your thoughts.
It's 3:58 in the ED and I'm thinking about how easy it is to spin a human in the wrong direction.
Bed 15 has lower back pain, an almost sure sign of drug addiction or seeking behavior when it presents at 2am. He had surgery 4 years ago- and still dabbles with cocaine. I think of my 9 month old, of how fragile her hair feels on my fingers when I run them through it every morning as I kiss her cheek. I wonder if he was ever held like that. What happened to this man? Who didn't give him what he needed, and how old was he when he didn't get it? Or did he have it all- and just make the mistake, one Thursday in 1989, of snorting a line of cocaine for the first time and liking it enough to try again. Bed 14, his neighbor, is convinced that she's going to die. She has sickle cell disease and comes in every 3-4 weeks with full body pain. Someone told her once, somewhere, that this is the common presentation of sickle cell "crisis" for which the treatment is pain medication and fluids. There is no good way to tell if the patients are actually feeling pain, and no good way to determine whether her misshapen red blood corpuscles are clogging arterioles throughout her body. So we treat her, over and over again, every other week or so. I wonder what she's really here for. When I touch her knee in an effort to examine the joint, she flinches. Was she abused once? Was it a family member?
My daughter's smile saves me from this awful thought, the way she looks at me definitively when she says "dada". The way she won't let me give her bites of dinner anymore because she's decided that now is the time for her to do things herself. What else will she do alone in this lifetime? Will she be safe? Will the consequences of her actions, and what comes her way lead her on a path of darkness? Will I give her enough tools to know herself and to be aware of her choices? Will she seek the highs that life provides without narcotics?
Room 4 is an elderly woman with a fever that has been explored for a month without a diagnosis. She has undergone procedure after procedure, blood draw after blood draw. She's been on multiple medications, the most powerful antibiotics, and her fever persists. Her husband is angry. He stands beside her, holds her hand. He looks at me with discontent and distrust as I enter. Her eyes are the same shade as my daughter's. I picture my little one, at age 63, and I hope that beside her will stand a man as honorable and kind as the man before me. I hope she finds a living guardian- a watchdog to be her advocate and her champion in times of need. These are the family members so often misinterpreted as "getting in the way," and yet these are the ones who save the lives of their loved ones by second guessing and demanding the truth and a plan and some action. Will my daughter be this strong willed? Will I teach her to be? Will I even need to?
I think of how easy it is to hold my baby in one arm; that each of us was as light once. Each had people make choices for us, until they were old enough to start making them for themselves- and so began a journey down the path of choices- choices ranging from utterly miserable and unfortunate and in the dark to self aware, and happy. And patients who travelled both roads are crowding the ED tonight with concerns and hopes. The concerns are different room to room. But both are, perhaps, hoping for the same thing- to return to a place, at 9 months old, where they could be be healthy; where they could be held- and told the right things, and treated the right way, and given the choice again to make a life for themselves, fingers running through their innocent hair, every tear wiped away with laughter and joy- with care- by someone who cared.
It's 3:58 in the ED and I'm thinking about how easy it is to spin a human in the wrong direction.
Bed 15 has lower back pain, an almost sure sign of drug addiction or seeking behavior when it presents at 2am. He had surgery 4 years ago- and still dabbles with cocaine. I think of my 9 month old, of how fragile her hair feels on my fingers when I run them through it every morning as I kiss her cheek. I wonder if he was ever held like that. What happened to this man? Who didn't give him what he needed, and how old was he when he didn't get it? Or did he have it all- and just make the mistake, one Thursday in 1989, of snorting a line of cocaine for the first time and liking it enough to try again. Bed 14, his neighbor, is convinced that she's going to die. She has sickle cell disease and comes in every 3-4 weeks with full body pain. Someone told her once, somewhere, that this is the common presentation of sickle cell "crisis" for which the treatment is pain medication and fluids. There is no good way to tell if the patients are actually feeling pain, and no good way to determine whether her misshapen red blood corpuscles are clogging arterioles throughout her body. So we treat her, over and over again, every other week or so. I wonder what she's really here for. When I touch her knee in an effort to examine the joint, she flinches. Was she abused once? Was it a family member?
My daughter's smile saves me from this awful thought, the way she looks at me definitively when she says "dada". The way she won't let me give her bites of dinner anymore because she's decided that now is the time for her to do things herself. What else will she do alone in this lifetime? Will she be safe? Will the consequences of her actions, and what comes her way lead her on a path of darkness? Will I give her enough tools to know herself and to be aware of her choices? Will she seek the highs that life provides without narcotics?
Room 4 is an elderly woman with a fever that has been explored for a month without a diagnosis. She has undergone procedure after procedure, blood draw after blood draw. She's been on multiple medications, the most powerful antibiotics, and her fever persists. Her husband is angry. He stands beside her, holds her hand. He looks at me with discontent and distrust as I enter. Her eyes are the same shade as my daughter's. I picture my little one, at age 63, and I hope that beside her will stand a man as honorable and kind as the man before me. I hope she finds a living guardian- a watchdog to be her advocate and her champion in times of need. These are the family members so often misinterpreted as "getting in the way," and yet these are the ones who save the lives of their loved ones by second guessing and demanding the truth and a plan and some action. Will my daughter be this strong willed? Will I teach her to be? Will I even need to?
I think of how easy it is to hold my baby in one arm; that each of us was as light once. Each had people make choices for us, until they were old enough to start making them for themselves- and so began a journey down the path of choices- choices ranging from utterly miserable and unfortunate and in the dark to self aware, and happy. And patients who travelled both roads are crowding the ED tonight with concerns and hopes. The concerns are different room to room. But both are, perhaps, hoping for the same thing- to return to a place, at 9 months old, where they could be be healthy; where they could be held- and told the right things, and treated the right way, and given the choice again to make a life for themselves, fingers running through their innocent hair, every tear wiped away with laughter and joy- with care- by someone who cared.
Tuesday, October 14, 2008
Who's job is it anyway?
This week I have had 3 patients with alcoholism. The first is a man who bled from varices, small veins in his esophagus. The second is a woman who drank so much in such short amount of time (3 months) that she went into liver failure. The last is a young man (25 years old) who drinks 24 beers a night and had bloody bowel movements for 2 weeks and ignored them until his mom threatened to kick him out of the house unless he came in. These three patients have very different stories, backgrounds, problems- but the common theme is alcohol. Alcohol ruined their lives- and alcohol ruined their bodies. And in each case I was called to fix them.
So here's the question: Alcoholism is a disease unlike others because the beginning, middle and end of the disease lie with people's choice to partake in a substance that is dangerous, mind altering, and one that eats stomachs, livers, blood, the brain, the heart- and other organs for lunch. This isn't like cancer or a heart attack- people literally choose to pick up the bottle again and again. Often times patients come in to the hospital several times before alcohol starts to really do its damage. Indeed on a given Saturday night, the emergency room is swamped with drunks- sometimes college kids who aren't yet hooked, but often by homeless men and women- many of whom have educations and had jobs and families lost to temptation and addiction. Given this- is it my job to stop the bleeding? Is it your job to pay for me to do so if these patients (2 of the 3 in my case this week) don't have insurance?
A friend of mine who works for an insurance company tells me that soon premiums will be significantly higher for smokers. The moral: If you choose to ruin your own body, you can pay the lions share of your health bills instead of your smoke-free neighbors. As a doctor it's tempting to agree with this policy. Why not make people more responsible for their habits- if those habits cost (in dollars and time) society at large.
The problem with this thinking is the dangerously slippery slope it represents. Why stop at smoking? Why not make alcoholics pay? And what about those rumors circulating that obese people will soon pay more for airline tickets? Should they pay higher premiums, too? And now that we're penalizing, how about anyone who ever sat on a tanning bed. The minute they get a melanoma diagnosis, should they poney up $2000 extra a month for 10 years to cover the cost of malignant melanoma in a small percentage of the melanoma population? Should I pay for a high carb diet? Should someone who recovered from a cocaine addiction pay for a heart attack 30 years later that may or may not be related? Should a man who slept once with a prostitute in Vietnam and contracted Hepatitis B be penalized monetarily forever more? And on and on the scenarios go...
It is indeed my job to fix whatever problems come my way, at any hour, on any patient. I swore an oath to that affect when I graduated from medical school. But somewhere in the next 50 years we are going to need a oath for everyone to live by- one of less recklessness and one of taking care of ourselves. We can barely afford to care for our sick compatriots now- and with the economy on the fritz- business has never been better at the liquor stores. Still, we are completely backwards in our thinking if we try to penalize with money after the fact. Many alcoholics spend their money on alcohol and don't have a lot left for insurance. Those obese folks could use some education and some support- like free gym memberships, or 1/2 hour extra a day at lunch to take a swim in a pool located at their workplace- now there's an idea. Most studies have shown that money towards health education pays off. As soon as a multi-million dollar campaign in India to educate truckers who were spreading HIV/AIDS throughout the country by unprotected sex with prostitutes was launched, the rates plummeted. And when that campaign was no longer funded- you know the rest.
To my alcoholic patients I had this to say after I "fixed" them this week: stop drinking or you are going to pay. And I wasn't talking for a second about money.
So here's the question: Alcoholism is a disease unlike others because the beginning, middle and end of the disease lie with people's choice to partake in a substance that is dangerous, mind altering, and one that eats stomachs, livers, blood, the brain, the heart- and other organs for lunch. This isn't like cancer or a heart attack- people literally choose to pick up the bottle again and again. Often times patients come in to the hospital several times before alcohol starts to really do its damage. Indeed on a given Saturday night, the emergency room is swamped with drunks- sometimes college kids who aren't yet hooked, but often by homeless men and women- many of whom have educations and had jobs and families lost to temptation and addiction. Given this- is it my job to stop the bleeding? Is it your job to pay for me to do so if these patients (2 of the 3 in my case this week) don't have insurance?
A friend of mine who works for an insurance company tells me that soon premiums will be significantly higher for smokers. The moral: If you choose to ruin your own body, you can pay the lions share of your health bills instead of your smoke-free neighbors. As a doctor it's tempting to agree with this policy. Why not make people more responsible for their habits- if those habits cost (in dollars and time) society at large.
The problem with this thinking is the dangerously slippery slope it represents. Why stop at smoking? Why not make alcoholics pay? And what about those rumors circulating that obese people will soon pay more for airline tickets? Should they pay higher premiums, too? And now that we're penalizing, how about anyone who ever sat on a tanning bed. The minute they get a melanoma diagnosis, should they poney up $2000 extra a month for 10 years to cover the cost of malignant melanoma in a small percentage of the melanoma population? Should I pay for a high carb diet? Should someone who recovered from a cocaine addiction pay for a heart attack 30 years later that may or may not be related? Should a man who slept once with a prostitute in Vietnam and contracted Hepatitis B be penalized monetarily forever more? And on and on the scenarios go...
It is indeed my job to fix whatever problems come my way, at any hour, on any patient. I swore an oath to that affect when I graduated from medical school. But somewhere in the next 50 years we are going to need a oath for everyone to live by- one of less recklessness and one of taking care of ourselves. We can barely afford to care for our sick compatriots now- and with the economy on the fritz- business has never been better at the liquor stores. Still, we are completely backwards in our thinking if we try to penalize with money after the fact. Many alcoholics spend their money on alcohol and don't have a lot left for insurance. Those obese folks could use some education and some support- like free gym memberships, or 1/2 hour extra a day at lunch to take a swim in a pool located at their workplace- now there's an idea. Most studies have shown that money towards health education pays off. As soon as a multi-million dollar campaign in India to educate truckers who were spreading HIV/AIDS throughout the country by unprotected sex with prostitutes was launched, the rates plummeted. And when that campaign was no longer funded- you know the rest.
To my alcoholic patients I had this to say after I "fixed" them this week: stop drinking or you are going to pay. And I wasn't talking for a second about money.
Wednesday, October 1, 2008
Shhhh it's a secret
Here are 10 things doctors think (and will never tell you).
10. You are going to die, and probably at age 76. One of the intriguing things about being a physician is that every illness has a beginning, a middle and an end. To patients, they have symptoms, they come in, they either get fixed or get worse. To us, the beginning holds the clues, the middle is where we meddle and the end is hopefully a successful remission of the illness, if not complete eradication. But in the end, something is going to begin that we can't stop. The middle may be a day or less, or months to years. But there will always be an end. This is apparent to us on the first day of anatomy when we meet our cadavers. And this is what makes doctors able to deliver terminal diagnoses with some regularity. It's not an easy fact. But it's life, and your doctor knows this and thinks about this more than most patients. For what it's worth, the average age of death in the US is 72 for males, 80 for females averaging 76.
9. We like it when you show that you care about yourself. This may seem like a no-brainer, but it is inevitably easier to take care of people who are making efforts to take care of themselves. We live in an interesting era- where malpractice lawyers eat doctors for lunch and patients read internet material and consider themselves experts. It's tough to be a doctor today, trust me, but nothing is more rewarding than the patient who shows up on time, and has made an effort to get better. I cannot tell you how many of my patients in my continuity clinics during residency skipped appointments, showed up 30 minutes late for a 30 minute appointment, stopped taking their medications-those who tried earned my internal respect. All were treated respectfully externally.
8. We're tired! I've written about the work hours before- but docs are beat. By the end of a day delivering health care we're emotionally exhausted and standing and bending and running around all day is tough. The good doctors will not try to hide this.
7. We are grossed out sometimes. So in my 2nd year of med school I rounded one night in the emergency room and a woman came in carrying her eye with the nerve dangling from her socket- I had to leave the room to avoid throwing up. Ever since then- many eye-related diseases weaken my knees- but this is one thing I can get over when I think from the patient's point of view.
6. MANY narcotics users are abusers. With the exception of patients with documented causes of their chronic pain, or patients with debilitating illness (cancers, etc) that require oxycontin, oxycodone, dilauded, morphine, fentanyl patches, or any others in the family of the most abused drugs in history- most patients prescribed these medications for unclear causes are abusing them and should be off of them. Almost all of my colleagues believe this to be so. Unfortunately, many of them prescribe them anyway.
5. We would do it again. I have asked many of my colleagues if, knowing what they know now about how tedious a path medicine is, from the start, they would pursue this path again. Most say a resounding yes. The truth is, we love our patients, our knowledge and our work. If we didn't, we'd never do this!
4. HOWEVER, we'd like to retire young and have second lives. The truth is, medicine takes a lot out of doctors, and most of us would love to pursue other passions as well. The problem is, the job takes up a LOT of time and energy- and there is a wave of young retirement among 50-60 year old docs and second careers which has left some hospitals with very young staffs and few senior physicians.
3. We hate malpractice lawyers. This may seem obvious, but every time I see an add from an ambulance chaser soliciting that "bad doctor" who "needs to be punished" I want to scream: 'you went to school for 3 years, did no residency or fellowship, made $150,000 the year you graduated (I am still making less than $60,000 4 years out), and don't have to deal with vomit and feces and blood and death all day!!'
2. We love to hear about patients' lives. The pleasure in my day, besides meeting amazing people and helping them feel better, is hearing their stories, and learning from them. Every time a patient recommends a book or a website I check it out. Most of my physician colleagues also embrace the chance to learn from our patients. You are our connection to the world at-large, and we are grateful.
1. We are afraid that health care in America is in BIG trouble. It's not just the uninsured, the insurance companies, politicians and CEOs who are worried about the crisis that is upon us, we docs worry about not being able to take care of all of you. We talk about it, read about it, vote according to it, keep up with it- we know that at the end of the day we are going to be in high demand, and that you may not have the means to pay for the services required to keep you healthy. These are scary times- and your doctors are equally scared.
10. You are going to die, and probably at age 76. One of the intriguing things about being a physician is that every illness has a beginning, a middle and an end. To patients, they have symptoms, they come in, they either get fixed or get worse. To us, the beginning holds the clues, the middle is where we meddle and the end is hopefully a successful remission of the illness, if not complete eradication. But in the end, something is going to begin that we can't stop. The middle may be a day or less, or months to years. But there will always be an end. This is apparent to us on the first day of anatomy when we meet our cadavers. And this is what makes doctors able to deliver terminal diagnoses with some regularity. It's not an easy fact. But it's life, and your doctor knows this and thinks about this more than most patients. For what it's worth, the average age of death in the US is 72 for males, 80 for females averaging 76.
9. We like it when you show that you care about yourself. This may seem like a no-brainer, but it is inevitably easier to take care of people who are making efforts to take care of themselves. We live in an interesting era- where malpractice lawyers eat doctors for lunch and patients read internet material and consider themselves experts. It's tough to be a doctor today, trust me, but nothing is more rewarding than the patient who shows up on time, and has made an effort to get better. I cannot tell you how many of my patients in my continuity clinics during residency skipped appointments, showed up 30 minutes late for a 30 minute appointment, stopped taking their medications-those who tried earned my internal respect. All were treated respectfully externally.
8. We're tired! I've written about the work hours before- but docs are beat. By the end of a day delivering health care we're emotionally exhausted and standing and bending and running around all day is tough. The good doctors will not try to hide this.
7. We are grossed out sometimes. So in my 2nd year of med school I rounded one night in the emergency room and a woman came in carrying her eye with the nerve dangling from her socket- I had to leave the room to avoid throwing up. Ever since then- many eye-related diseases weaken my knees- but this is one thing I can get over when I think from the patient's point of view.
6. MANY narcotics users are abusers. With the exception of patients with documented causes of their chronic pain, or patients with debilitating illness (cancers, etc) that require oxycontin, oxycodone, dilauded, morphine, fentanyl patches, or any others in the family of the most abused drugs in history- most patients prescribed these medications for unclear causes are abusing them and should be off of them. Almost all of my colleagues believe this to be so. Unfortunately, many of them prescribe them anyway.
5. We would do it again. I have asked many of my colleagues if, knowing what they know now about how tedious a path medicine is, from the start, they would pursue this path again. Most say a resounding yes. The truth is, we love our patients, our knowledge and our work. If we didn't, we'd never do this!
4. HOWEVER, we'd like to retire young and have second lives. The truth is, medicine takes a lot out of doctors, and most of us would love to pursue other passions as well. The problem is, the job takes up a LOT of time and energy- and there is a wave of young retirement among 50-60 year old docs and second careers which has left some hospitals with very young staffs and few senior physicians.
3. We hate malpractice lawyers. This may seem obvious, but every time I see an add from an ambulance chaser soliciting that "bad doctor" who "needs to be punished" I want to scream: 'you went to school for 3 years, did no residency or fellowship, made $150,000 the year you graduated (I am still making less than $60,000 4 years out), and don't have to deal with vomit and feces and blood and death all day!!'
2. We love to hear about patients' lives. The pleasure in my day, besides meeting amazing people and helping them feel better, is hearing their stories, and learning from them. Every time a patient recommends a book or a website I check it out. Most of my physician colleagues also embrace the chance to learn from our patients. You are our connection to the world at-large, and we are grateful.
1. We are afraid that health care in America is in BIG trouble. It's not just the uninsured, the insurance companies, politicians and CEOs who are worried about the crisis that is upon us, we docs worry about not being able to take care of all of you. We talk about it, read about it, vote according to it, keep up with it- we know that at the end of the day we are going to be in high demand, and that you may not have the means to pay for the services required to keep you healthy. These are scary times- and your doctors are equally scared.
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