Let Them Die

[DaveinElma]

i'd bet your estimate is extremly low although the data doesn't come quickly to hand. we have 49 million uninsured. a pretty small percentage have to get critically ill to blow your guess out of the water. how many belljars of coins ones and 5's equates to the cost of 1 ICU day? while admirable, this is largely symbolic.

 

My point is that cases like that always get major media attention and private charities, churches, and the business community always step up and do their part.

[OCinBuffalo]

http://2012.talkingp...e-die-video.php

 

Horrible people

You didn't watch the video, did you? The number of people that "cheered" in the crowd is directly proportional to the number of US citizens that think Obama's new "jobs plan" will pass the Senate without amendments, never mind the House.

I wouldn't cheer about it like it was a football game but yes a person who can afford insurance but chooses to roll the doesn't deserve one ounce of pity.

But they didn't cheer. Dave's thread is based on an article that is based on either a baldfaced lie or a distortion from someone who's brain obviously suffers from affectation, and, the assumption people wouldn't watch the video.

[ieatcrayonz]

Ok, then if there was mandated insurance, the death decision would be ruled by a panel's determination of acceptable care, which wouldn't prevent death. How is that different?

 

I'm guessing that his answer would be a greater role for charitable organizations to fill in for people in need.

 

 

Aren't "society" and "government" two different things?

[BillsFanM.D.]

do you have an advanced directive explicitly stating your desire for no heroic measures?....rhetorical question, don't really want to know.

 

No time to get into this whole mess. Too much flooding in my area. However, advanced directives are not all that they are cooked up to be. They almost all have an implied clause that states something to the effect of: "in the even that x,y or z doctor deems my situation 'hopeless' I do not want 'this or that.'

 

It leaves the doctor 'in the moment' to determine, along with the family, what is and is not hopeless. Based on whose values/quality of life/truly living? You can imagine the countless debates that ensue between the family members who 'really' know the patient and the long lost brother who now 'wants to be in charge' and has a lawyer etc.

 

In addition, many folks want "cpr" and defibrillation but do not want to be intubated. It is often spelled out that way in their living wills. That's nonsense. They all happen simultaneously in many situations and all are essential to have a chance to survive (in many circumstances). Defibrillation may or may not be necessary but that's another discussion. I cannot tell you how many times folks would bring in a living will for their relative (who had an arrest outside the hosp and were treated with emergency protocols and intubated) and it stated that he 'would not want to be intubated.' In these situations, the patient is already stabilized and many times extubated within 48 hours. The family member almost always says that 'this short term ventilator use is fine'. 'He just didn't want to be on it 'forever.'' I've NEVER had a patient recover and say I didn't want to be on that vent the last two days.

 

This is the most common misconception I have seen...and I've seen it many times. Folks check off the box (most of these are boilerplate forms) that says they would not want to be on a vent thinking it means long term.

 

Do yourselves a favor and designate a medical power of attorney and have an honest and frank talk about what you would want and what you wouldn't. Designate them (and several backups) to be the voice you cannot be. A form can speak for you to a degree but every situation is unique and flexibility is necessary most of the time. Besides, if there is no readily apparent form or medical POA present, the patient is going to get the full court press regardless. If they are then left dependent on the machines and not 'recovering' after a period of time, having a person who knows you is much better than a standardized form. Just my 2 pennies from 'the other side.'

[OCinBuffalo]

Aren't "society" and "government" two different things?

Not if you're Canadian.

 

do you have an advanced directive explicitly stating your desire for no heroic measures?....rhetorical question, don't really want to know.

No time to get into this whole mess. Too much flooding in my area. However, advanced directives are not all that they are cooked up to be. They almost all have an implied clause that states something to the effect of: "in the even that x,y or z doctor deems my situation 'hopeless' I do not want 'this or that.'

 

It leaves the doctor 'in the moment' to determine, along with the family, what is and is not hopeless. Based on whose values/quality of life/truly living? You can imagine the countless debates that ensue between the family members who 'really' know the patient and the long lost brother who now 'wants to be in charge' and has a lawyer etc.

 

In addition, many folks want "cpr" and defibrillation but do not want to be intubated. It is often spelled out that way in their living wills. That's nonsense. They all happen simultaneously in many situations and all are essential to have a chance to survive (in many circumstances). Defibrillation may or may not be necessary but that's another discussion. I cannot tell you how many times folks would bring in a living will for their relative (who had an arrest outside the hosp and were treated with emergency protocols and intubated) and it stated that he 'would not want to be intubated.' In these situations, the patient is already stabilized and many times extubated within 48 hours. The family member almost always says that 'this short term ventilator use is fine'. 'He just didn't want to be on it 'forever.'' I've NEVER had a patient recover and say I didn't want to be on that vent the last two days.

 

This is the most common misconception I have seen...and I've seen it many times. Folks check off the box (most of these are boilerplate forms) that says they would not want to be on a vent thinking it means long term.

 

Do yourselves a favor and designate a medical power of attorney and have an honest and frank talk about what you would want and what you wouldn't. Designate them (and several backups) to be the voice you cannot be. A form can speak for you to a degree but every situation is unique and flexibility is necessary most of the time. Besides, if there is no readily apparent form or medical POA present, the patient is going to get the full court press regardless. If they are then left dependent on the machines and not 'recovering' after a period of time, having a person who knows you is much better than a standardized form. Just my 2 pennies from 'the other side.'

Since both of you are physicians, I have a question: how much time do you devote to ADs with your patients? How much time do you think the average doc does? The reason I ask is: you may know I am well-acquainted with the requirements for ADs in terms of data collected and the intended process to create it. However, I rarely see either executed properly in code, and I see even less data. In most systems, it amounts to a dead feature, meaning nobody uses it, or, what little use it did have died out after the first 6 months the system was deployed. 2 times out of 100s I have seen it done right, and those were direct responses to surveyor deficiencies.

 

Most of the time, DNR amounts to a friggin checkbox , with no link to the supporting document, not even a place/contact person for where the doc/and or specifics can be obtained. In terms of real world use, a checkbox may be practical, but not for all users, all the time. Certainly not when specifics are required, immediately. ADs are even worse. Most of the time I see just a few more check boxes. I have news: check boxes '= flexibility. Giving the user the ability to create more checkboxes doesn't create "flexibility" either. Not the kind of flexibility you are talking about BillsFan. It just creates more checkboxes.

 

Is this because doctors/nurses don't spend any time on DNRs/ADs? And finally: both of you put this in terms of "you can go get a form/lawyer/DIY". Why? I'm curious only: isn't this a service that a doctor should provide, rather than a lawyer?

[....lybob]

The answer Ron Paul should have given is this " of course he'd get medical care, we are a civilized and humane country that believes life is sacred but when he woke up and got better he'd have his medical bills waiting, then he'd have a choice of working out a repayment of those bills or bankruptcy"

 

The question was kinda stupid and the answer was stupid

[Rob's House]

Can any of our morally superior friends give an honest answer to this question: At what point do you draw rhe line or do you draw no line and spend whatever it costs to prolong every life as long as possible?

 

The answer Ron Paul should have given is this " of course he'd get medical care, we are a civilized and humane country that believes life is sacred but when he woke up and got better he'd have his medical bills waiting, then he'd have a choice of working out a repayment of those bills or bankruptcy"

 

The question was kinda stupid and the answer was stupid

I was thinking along those lines, but you'd have to have some measures do discourage bankruptcy beyond risking bad credit for 7 years.

[birdog1960]

i discuss advance directives at least 3 visits per day when i do medicare wellness exams. initially this was a required element of this newly compensated visit but now is optional due to the furor over "death panels". i do it anyway, every time. and while they are imperfect instruments, they are much better than nothing especially when i have charted the patients wishes. we also discuss the need for a designated medical decision maker. i actually see more and more octagenarians opt for unambiguous "no intubation, no code" orders although i don't purposefully steer people this way. if they ask what i'd do (they often do) and they are very frail and infirm, i tell them that i wouldn't have heroic measures done.

 

rob asks "how much is too much?" a valid question but there are many low hanging fruit cases to stop futile care on before we pull the plug on the young, healthy accident victims. futile care is extremely prevalent and usually obvious to all outside observers. i'm on the ethics committee for my hospital and we're confronted with these cases frequently. i find it incredible that some on the right scream and shout about witholding care based on ability to pay while at other times we hear the yelling for continuing care forever on near hopeless cases (eg schiavo). i wonder if some of the same people make both arguments simultaneously.

 

btw, my motive in mentioning advance directives had much more to do with the possibility of valuing a faceless, uninsured, unknown persons life less than your own than it did with introducing the instrument.

Edited September 14, 2011 by birdog1960

[BillsFanM.D.]

Not if you're Canadian.

 

Since both of you are physicians, I have a question: how much time do you devote to ADs with your patients? How much time do you think the average doc does?

 

Most of the time, DNR amounts to a friggin checkbox , with no link to the supporting document, not even a place/contact person for where the doc/and or specifics can be obtained. In terms of real world use, a checkbox may be practical, but not for all users, all the time. Certainly not when specifics are required, immediately. ADs are even worse. Most of the time I see just a few more check boxes. I have news: check boxes '= flexibility. Giving the user the ability to create more checkboxes doesn't create "flexibility" either. Not the kind of flexibility you are talking about BillsFan. It just creates more checkboxes.

 

Is this because doctors/nurses don't spend any time on DNRs/ADs? And finally: both of you put this in terms of "you can go get a form/lawyer/DIY". Why? I'm curious only: isn't this a service that a doctor should provide, rather than a lawyer?

 

I think it is a priority and I make it so. It was also stressed as a part of my training. "You have to document Code Status." as for other folks...not so sure. Some do it very well and some avoid it like a disease. Should be addressed as part of routine health maintenance. Certainly should be addressed with every hospital admission.

 

I totally agree that the check boxes offer no wiggle room. Hence, as noted in my original post, I prefer the designation of a medical power of attorney. That person will give the 'directions' on what is and is not to be done. They can be flexible whereas the check box is literally black and white. They can listen to other loved ones; doctors; nurses and make an informed decision for 'you' based on what is almost always a fluid and day to day situation.

 

I typically tell patients to avoid AD's in the form of living wills. I, personally, find them to be nearly useless for all the reasons I stated above. They are rarely on hand when needed in an emergency; offer no flexibility; and are very ambiguous in language: "in the event that things are deemed hopeless...." In addition, a medical person should be present to explain the check boxes if they choose to go that route.

 

I typically do tell patients to have a formal document drawn up and at least notarized. I have served as the 'other signature' along with a witness on many of those types (with no lawyer involved). Having said that, I have also written a note in a patient's chart; had them sign it and have a family member and staff member witness it (Pre-EMR days). That depends on the relationship the doc has with the patient/family.

 

The doctor does need to provide his side of the 'service' as you pointed out. By my definition that includes: explaining the options/weaknesses of both living will check boxes and medical POA (be careful who you choose and make sure they know you); explaining the implications of each and the applications of each; provide scenarios and point out how each would work in the real world etc.

 

In today's world, it is probably better for a legal person to draw up the actual document just because if a dispute develops in the family it theoretically has a bit more leverage. Hence, I think it is better to have a formal item but it doesn't prevent me from 'doing it myself' in the right situation.

Edited September 14, 2011 by BillsFanM.D.

[Gary M]

This is all a distraction.

 

The question is can the Obama adminstration mandate that a US citizen has to buy insurance?

[GG]

how bout this: the guy did have private insurance but his maximum benefit of $500K is exceeded in 6 months and he's still on a ventilator. he has savings of a few thousand (enough for about 6 hours in the ICU). should the tube be pulled and he be left to die? if not, who should pay?

 

OK, how about this? 90% of your clients are covered by insurance and fully pay on time. With the other 10%, you will not be paid and you have to make a decision of whether to treat them, for how long, or to turn them away. Would you sign up for that system?

[KD in CA]

Good, I finally got you to admitted you are one of the same.

Wow, I can't believe you finally cracked that case! Impressive work. Tom held out for a long time on that secret identity.

 

 

 

how bout this: the guy did have private insurance but his maximum benefit of $500K is exceeded in 6 months and he's still on a ventilator. he has savings of a few thousand (enough for about 6 hours in the ICU). should the tube be pulled and he be left to die? if not, who should pay?

And here's the problem. We can invent scenarios all day long to score political points and yet nobody is addressing the issue (note: I didn't see or read anything about this debate) of what do we do with terminally ill people who continue to burn through millions of dollars in health-care costs? Less than a week before my father died of cancer they were still giving him radiation treatments. We were all standing around the bed wondering "when is one of these doctors going to acknowledge that he's is going to die any minute?" Hospice care costs about one-tenth as much as hospital care, yet rather than putting people in those facilities, we are actually closing them down.

[UConn James]

This is all a distraction.

 

The question is can the Obama adminstration mandate that a US citizen has to buy insurance?

 

That issue looks like it's headed for the Supremes.

 

But really, to a certain extent, this already is in effect. I am uninsured and when I got bitten by a pit bull derivative while walking in the road with my dog earlier this year, after the ER visit, my primary doc had to call around specialists... who didn't want to know me from nothin' until one of them asked if there was going to be a lawsuit. When the doc's secretary asked me that and I said yes, I had an appointment for two days later. Say what you want about the Hippocratic Oath, but there's a certain degree of discouraging or holding out on expensive treatments for people who won't be able to afford it.

 

The stink of it is, during that whole thing, my dog got better care for more serious wounds at the vet for ~ $400 vs. me with our medical system for ~ $3,000 (so far). The cost structure is so far out of whack it's unbelievable. And Obamacare does nothing to address that besides a vague HOPE that it'll CHANGE. Newsflash: adding users into the system does not force prices downward.

Edited September 14, 2011 by UConn James

[Joe Miner]

Blitzer asked if under Paul’s libertarian philosophy, a sick man without insurance should be allowed to die in the hospital rather than have the state pay his medical bills.

 

That's really not what happened in the video at all.

 

The direct question was "Are you saying that society should just let him die?"

[DC Tom]

Good, I finally got you to admitted you are one of the same.

 

Seriously? It's not like it was a secret, you mincing little pansy.

[birdog1960]

Wow, I can't believe you finally cracked that case! Impressive work. Tom held out for a long time on that secret identity.

 

 

 

 

And here's the problem. We can invent scenarios all day long to score political points and yet nobody is addressing the issue (note: I didn't see or read anything about this debate) of what do we do with terminally ill people who continue to burn through millions of dollars in health-care costs? Less than a week before my father died of cancer they were still giving him radiation treatments. We were all standing around the bed wondering "when is one of these doctors going to acknowledge that he's is going to die any minute?" Hospice care costs about one-tenth as much as hospital care, yet rather than putting people in those facilities, we are actually closing them down.

totally agree...see my comments on futile care. and reimbursement should be tied to outcomes rather than volumes with the caveat that a well managed death is sometimes a desirable outcome. but all of this is so arbitrary as noted with the fight over persistent vegetative states. why is it ok to deny care from the uninsured (according to some) but not ok to deny it from medicare recipients that receive on average multiple times what they paid in to the system. we have over 350000 patients on dialysis in the us at an average cost of about $70000 per year (most all paid for by medicare). most have an incurable illness. if we're not gonna help the young accident victim should we be paying for dialysis in the elderly. it's a question americans are loathe to ask. it's a question asked and answered in many countries with socialized medicine.

[GG]

totally agree...see my comments on futile care. and reimbursement should be tied to outcomes rather than volumes with the caveat that a well managed death is sometimes a desirable outcome. but all of this is so arbitrary as noted with the fight over persistent vegetative states. why is it ok to deny care from the uninsured (according to some) but not ok to deny it from medicare recipients that receive on average multiple times what they paid in to the system. we have over 350000 patients on dialysis in the us at an average cost of about $70000 per year (most all paid for by medicare). most have an incurable illness. if we're not gonna help the young accident victim should we be paying for dialysis in the elderly. it's a question americans are loathe to ask. it's a question asked and answered in many countries with socialized medicine.

 

Medicare is socialized medicine. Yet as you admit, no one is asking the questions. The reason no one is asdking is that the costs are buried and consumers have no clue of what the true cost of care is, while the medical profession has built a nice business by knowing excatly who & how much to charge to keep the wheels rolling.

 

Now, before we move on, answer my earlier question.

[birdog1960]

OK, how about this? 90% of your clients are covered by insurance and fully pay on time. With the other 10%, you will not be paid and you have to make a decision of whether to treat them, for how long, or to turn them away. Would you sign up for that system?

i see many uninsured patients and make no distinction about who to see based on insurance. we actually discount fees for the uninsured so that there isn't a penalty for them to pay more because they have no one to negotiate on their behalf (and they are generally good payers). we have payment plans and do require a good faith effort to pay but the definition of good faith is case by case. very few patients are told to go elsewhere for overdue bills or being in collections but there are some. 30 day collections are lower than 90% (if that's how you define prompt) so i would be very happy with the model you proposed. we would, however, still attempt to collect from the uncovered 10%.

 

and the reason these questions aren't addressed is not buried costs. it's because it's a political graveyard. we saw it with the recent healthcare debate when in one sentence people were just saying no to socialized medicine and in the next saying "don't touch my medicare". denying care is ok with many americans as long as it's not their care that's being denied or rationed.

Edited September 14, 2011 by birdog1960

[OCinBuffalo]

Medicare is socialized medicine. Yet as you admit, no one is asking the questions. The reason no one is asdking is that the costs are buried and consumers have no clue of what the true cost of care is, while the medical profession has built a nice business by knowing excatly who & how much to charge to keep the wheels rolling.

 

Now, before we move on, answer my earlier question.

Wouldn't it be amazing if somebody could create a core architecture, but, make it extensible to the point of appearing to be custom software, that could deal with each care user as individuals, so that we get usage rates at 98%, which therefore gives us highly accurate data in general, that in turn allows us to produce highly accurate cost of doing business information in health care?

 

How awesome would the guy be who could do that for us?

[Peace]

Seriously? It's not like it was a secret, you mincing little pansy.

 

But who is The Telephone Pole?

 

Wouldn't it be amazing if somebody could create a core architecture, but, make it extensible to the point of appearing to be custom software, that could deal with each care user as individuals, so that we get usage rates at 98%, which therefore gives us highly accurate data in general, that in turn allows us to produce highly accurate cost of doing business information in health care?

 

How awesome would the guy be who could do that for us?

 

Sounds like a hack programmer, and not a particularly imaginative one. Software won't cure the ills OCnarcissist.