More excerpts from last night's ABC transcript:
DR. MICHAEL JENSON, MAYO CLINIC: I'm Dr. Michael Jenson at the Mayo Clinic in Rochester, Minnesota. I see too many patients who have terminal illnesses or no hope of recovery who receive weeks or months of intensive care unit treatment, only to prolong their death. I find this approach very distressing and the waste of money is appalling. . . .
ROBERT WASSON: My name is Robert Wasson. My mother is 74 years old. She has terminal cancer in the stomach lining that has spread to the lungs. She deserves to be treated medically to the best of their ability. To say it's too expensive is not right. I just don't think you can put a price tag on quality time with loved ones, especially at the end of their lives.
OBAMA: Well, and -- and that's absolutely true. And end-of-life care is one of the most difficult sets of decisions that we're going to have to make. I don't want bureaucracies making those decisions, but understand that those decisions are already being made in one way or another. If they're not being made under Medicare and Medicaid, they're being made by private insurers. We don't always make those decisions explicitly. We often make those decisions by just letting people run out of money or making the deductibles so high or the out-of-pocket expenses so onerous that they just can't afford the care. And all we're suggesting -- and we're not going to solve every difficult problem in terms of end-of-life care. A lot of that is going to have to be, we as a culture and as a society starting to make better decisions within our own families and for ourselves. But what we can do is make sure that at least some of the waste that exists in the system that's not making anybody's mom better, that is loading up on additional tests or additional drugs that the evidence shows is not necessarily going to improve care, that at least we can let doctors know and your mom know that, you know what? Maybe this isn't going to help. Maybe you're better off not having the surgery, but taking the painkiller. [The adjective "necessarily" carries significant weight here. What about treatment that has SOME probability of improving care?]
2 comments:
This excerpt shows the problem. Population based evidenced based medicine doesn't work when applied to the individual.
I recently took care of a gentleman with metastatic non-small cell lung cancer. When he died, I had treated him with SIX different lines of chemotherapy. He lived 4.5 years. Obviously, not the norm on multiple fronts. I DO think that I prolonged his life. He responded VERY well to everything that I gave him until the last.
If I were using only evidence based medicine, I would have never had treated him for so long, and he would died sooner.If I were using Obama care, I could not have justified his ongoing treatment, and he would have died sooner.
Evidenced based medicine would suggest that very aggressive care/testing is not going to work in a multitude of cases. However, most physicians have taken care of that rare, exceptional case when what seemed impossible did work. That experience drives a lot of the additional care, because "we just don't know and it's impossible to predict the future." Families, having heard of these miracle level cases demand more care, hoping that their loved one will be the miracle. They are unaware of the diminishing returns of super aggressive therapy. They are unaware of how much suffering super aggressive therapy may invoke and how that will likely reduce the quality of life that person has.
"I just don't think you can put a price tag on the quality time with loved ones, especially at the end of their lives." When family members demand that people with terminal disease have "everything" done, they do not realize that they may not be purchasing quality time with their loved one and only a prolonged death. The problem in my field: to aggressively treat that person with metastatic cancer (i.e. put them in the unit on a ventilator with pressors) will likely not prolong their lives (but we don't know because we aren't god); however, it will remove money from a limited pot so that someone, who is walking around and has a much higher likelihood of benefiting from palliative treatment, will not get that treatment.
There is no way to apply population based evidenced based medicine without forcing inappropriate "rationing" on some. Not all care can be provided to all people without breaking the bank, and then, unfortunately, there will be no care for a greater number. That sucks, but it is the reality.
Thank you Celeste.
Obama is certainly correct that we can be guided by EBM. But any guidance from EBM must be mediated by value-laden maxims.
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