tag:blogger.com,1999:blog-9181810725696409953.post1284220506316942135..comments2024-03-17T04:20:11.083-04:00Comments on The Population Health Blog: Dr. Gawande, Hospice, The New Yorker and the Curious Absence of Some Inconvenient Truths: Here's the Rest of the StoryJaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.comBlogger7125tag:blogger.com,1999:blog-9181810725696409953.post-24233027529967922242010-09-23T14:23:24.135-04:002010-09-23T14:23:24.135-04:00The survey of survivors says to me the opposite of...The survey of survivors says to me the opposite of what you intend with it. 30% of people who win the medical lottery and survive their stay in the ICU wouldn't do it over if they could go back again! That's shockingly high to me. These are the fortunate ones! <br /><br />I also don't think it's reasonable to describe hospice as "pulling the plug", its just prioritizing quality of life over quantity of life. For every patient with a very poor prognosis who makes it, several, possibly dozens or hundreds, will have their health destroyed prematurely by traumatic low odds treatments. We're not talking about taking away people's options but rather being responsible enough to inform them of the honest costs and benefits of their choices.<br /><br />Frequently patients will feel that lower cost courses of treatment offer a higher value set of contingencies than more expensive ones. Do people really need to make themselves miserable in the last months or weeks of life just to squeeze every last nickel out of those greedy insurers?Hankhttps://www.blogger.com/profile/07323974751772818060noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-78743222048487715722010-09-15T22:42:35.614-04:002010-09-15T22:42:35.614-04:00source for Arthur Kleinman quote was Mount Sinai J...source for Arthur Kleinman quote was Mount Sinai Journal of Medicine, volume 73, 2006.erichttps://www.blogger.com/profile/16137189911651175163noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-87549627041462374042010-09-15T22:40:37.426-04:002010-09-15T22:40:37.426-04:00The issue is deeper than a doctor's inability ...The issue is deeper than a doctor's inability to predict a person's last illness or a person's inability to choose what they might want done in every possible situation. It is a spiritual matter of deciding at some point that I won't be greedy for more life and will accept the end no matter how it comes. "Is there a duty to die?" asked John Hardwig in The Hastings Center Report, volume 27, 1997. Arthur Kleinman exhorts us to avoid medicalizing a normal process and to recognize that people near the end of life "are experiencing serious suffering, a crucial<br />moral condition: one that doctors of past generations<br />recognized and dealt with as fundamental to<br />living and dying with meaning...When what is often needed is<br />a conversation opener so that people at the end of<br />life can express and explore the most tellingly<br />human of fears and concerns."erichttps://www.blogger.com/profile/16137189911651175163noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-48766991314056570462010-08-02T19:10:46.629-04:002010-08-02T19:10:46.629-04:00The "problem" with advanced directives i...The "problem" with advanced directives is they primarily direct when one has no hope for meaningful recovery. The harder discussion is how to express one's health choices and values prior to those situations that might put you in a permanent vegetative state (such as complex open heart surgery in someone who already has poor lung and kidney function0<br /><br /><a href="http://www.amazon.ca/Let-Me-Decide-Dr-Molloy/dp/0143055496" rel="nofollow">This book</a> has, in my experience, one of the best approaches to such a discussion. It doesn't require a doctor or a governmental bureaucrat or an insurance nurse. And <a href="http://www.wagpnetwork.com.au/client_images/177702.pdf" rel="nofollow">here's</a> and example of the form.Phil 314https://www.blogger.com/profile/04133300763922742206noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-6208637382133094272010-08-02T16:06:20.324-04:002010-08-02T16:06:20.324-04:00Unlike Atul Gawande's piece,to a bystander you...Unlike Atul Gawande's piece,to a bystander your post is unclear and poorly argued (maybe understanding the links help); your inconvenient truths seem murky or unrelated. In particular, whether the people who survived ICU would do it all over again is a weak argument. I want the best quality of life overall, including all the futures in which I die.<br /><br />Your cynical first answer to "why the interest in changing things?" is an insult. Millions of people die every year receiving medical care they didn't ask for and don't want. Everyone thinking about that, including you, is a hero. (And it doesn't BEG the question, it RAISES it.)skierpagehttps://www.blogger.com/profile/04480517078252023572noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-19419255713694754592010-07-31T07:48:27.118-04:002010-07-31T07:48:27.118-04:00It's ironic that with the government's for...It's ironic that with the government's foray into going beyond just PAYING for health care ("usual and customary") to promoting QUALITY that there was such political blowback over EOL care. Like it or not, health care consumers will never trust Medicare on the issue, because it now shares in the same conflict of interest.<br /><br />What would I do?<br /><br />First off, the percentage of costs occupied by EOL care has remained stable over the years: if we want to reduce that cost, we have to reduce TOTAL health care costs, i.e., bend the curve.<br /><br />Secondly, I'd forget about any big band solutions: a bill, a regulation, a speech. This is a journey that will take at least a decade, and it's small steps, including the promotion of ground level quality initiatives that promote the discussion between provider and patient; for example, many disease management have been routinely doing this because it is a long established feature of care planning.<br /><br />AND as mentioned in my blog, I'd start looking at the extremes of one side of the tail of variation with credible measures, such as the percent of patients getting aggressive treatment within "X" days of death. If it's high, that's a problem. It should be in a medium range. There is probably good benchmark data out there: let's find out what it is and make sure it fits with consumer expectations.<br /><br />Last but not least, this may be were Berwick's "Confessions of an Extremist" could help in real world terms. Patients have an absolute right to make the calls. Using the right kind of Shared Decision Making could make a difference.Jaan Sidorovhttps://www.blogger.com/profile/05072456803925863874noreply@blogger.comtag:blogger.com,1999:blog-9181810725696409953.post-55128547580314008422010-07-30T14:44:48.902-04:002010-07-30T14:44:48.902-04:00"As a result, government and commercial insur..."As a result, government and commercial insurers have a considerable economic incentive to steer patients with a poor prognosis away from costly health care services." ... Well yes, Jaan, but since it's pretty much all of us who are paying taxes and/or insurance premiums, this is an economic incentive in which we all have an interest. So, how should we control end-of-life costs?Roger Collierhttp://www.reformupdate.blogspot.comnoreply@blogger.com