The Chicago Tribune explores a question that will be increasingly asked over the next few years: Should physicians, as some in Chicago
The article reviews the widely-published arguments of Daniel Callahan. I am glad these discussions are getting much greater public exposure. This will help inform and spur a much-needed societal debate. I like much of Callahan's argument, but think that while age might be one relevant factor, I think the answer to these questions should focus more on the capacity to benefit.
3 comments:
Yes! We need to have an HONEST conversation about "too old for lifesaving but expensive procedures!" and we should look at the medical and the fiscal futility input by the reigning bioethicists who do not always agree on the values to be protected -- and who are only human beings, themselves, who do not have all the answers and who work for a living.
Ethics committees within hospitals have a definite conflict of interest because of the fiscal futility input that bears on the financial health of the institution they work for directly or in an agency relationship.
When hospitals, because of administrative rules governing reimbursement, are not reimbursed for ICU time for the elderly patients, unauthorized passive euthanasia of elderly patients becomes a solution to curbing the costs to the hospital.
But the subject matter is such a political bomb shell. Passiive euthanasia without patient consent is against the law. The ethical, moral, fiscal, medical and LEGAL realities concerning "death with dignity" etc. invite conflict over which values and goals of our great democratic Republic should be protected.
Is there a terrible danger to our humanity that we aren't looking at because we won't look at any solutions that might overall in any manner impact profits negatively?
What about the "futility" of treating the very old patients to begin with in the outpatient setting?
Why weren't physicians and private clinics, etc.. included in the provisions of the 1991 Patient Self Determination Act? Why did the AMA lobby against this?
It is certainly obvious that it is the physicians and clinics who earn profits as corporations who should be mandated by law to talk to elderly patients about "end of life" choices at the beginning of the recommended outpatient treatment.
Isn't it obvious that the physicians should be legally mandated to seek informed consent for palliative and hospice care at the beginning of recommended outpatient treatment? But, are "profits" the one value that we won't put out on the table?
Isn't this a relevant factor that should also be put out on the table for discussion?
These arguments always tend to focus on that which is not, IME, the main cause of skyrocketing Medicare costs. As an example, I have seen many folks referred to hospice by their physicians and unabe to participate because, when released to an LTC, TPTB at the facility decide to "skill" them, getting paid for various restorative therapies with the chance of a snowball in Hades of provding any benefit - except to the facility's bottom line. They always get a bed because even if restorative is ruled out they get three days of the higher Medicare skilled rate, their census is up, and corporate is assuaged. And hang around during CMI - case mix index - period. Every resident's chart is investigated with a fine-toothed comb to raise their acuity - which is reimbursed at a higher rate for the next six months. Doctor's visits are scheduled, everyone gets picked up by PT/OT/ST for a time - the only ones exempted are in end-stage AD and can barely swallow their pureed meals. And then there're the EOL people who linger in ICU because the family wants "everything" done.
You gotta replace a bad hip even if the person won't walk again. It HURTS to live with broken bones. But we don't have to skill the 92-y.o. who just had it done.
But again! It depends on the individual. My Mother broke her hip at 99-l/2 and I sensed that the system wanted to give up on her. (In fact, I complained to the Hospital about age discrimination because they waited so long to repair the hip fracture and endangered her.) But, a very good PT within the Nursing Home worked with her and Mom tried hard because we told her she could come home as soon as she could transfer her weight, etc... and use a walker.
She did come back home and was active for another three years before she had to use a wheel chair, and died at 104-l/2 after a small stroke.
Age alone is not a reliable criteria on which to withhold treatment and is, of course, age discrimination under the law.
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