Treating Elderly with Chronic Diseases - Adding Life?

Rosemary Flanigan, PhD
November 25, 2008

Two events this past week seemed to coalesce: Dr. Rob Martensen came from the National Institutes of Health to talk about his new book, A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era and TIME magazine’s cover story was “The Sorry State of American Health.”

Rob spoke about healthcare for the elderly suffering from chronic diseases which too often offers to treat when there is little advantage to the treatment and side-effects that, though mentioned as they must be, are often not explored with the patient who might reject the treatment if he/she knew more.

Then along comes TIME, reporting that the U.S. spends16% of GDP on healthcare, the highest than any other nation. (“One benefit of all that spending is that the U.S. leads the world in medical innovation. Hospital care remains the largest expense, driven by demand from an aging population.” The healthcare dollar is spent as follows here: $ .32, hospital care; $ .21, physician and clinical services; $ .10, prescription drugs; $ .09, nursing-home care; $ .07, administrative costs; $ .04, dental care; $ .04, equipment; $ .02, research; $ .12, all other)

The U.S. ranks just 34th in the world in life expectancy, at 77.9 years. Rob told us that in the 1980’s a Swiss demographer, Arthur Imhof, published a series of papers that looked at human life and medical progress through the lens of four hundred years: life expectancy has barely changed in those four hundred years!

“Despite the ingenuity of medicine’s panoply of late-life interventions, and putting aside their huge cost, inconvenience, and the suffering associated with using some of them, technologically advanced interventions appear to add little additional life for those in their ninth and tenth decades.”

Sobering thoughts. There will never be a dearth of possibilities for ethics committees to intervene in end-of-life care. What other domains we may enter, end-of-life will offer us ready opportunities for reflection and counsel.

What do you think? Click here to share and view comments.

Stewardship of Scarce Resources

Rosemary Flanigan
November 21, 2008

I know that the good people who come to monthly ethics brown bag sessions (mostly chaplains and CPE students, a few nurses, a few “others”) have nothing to do with the Charity care budget entry, but I am using the New York Times story of the “haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill.” (Nov. 9, 2008 issue)

Not that we all go “tsk, tsk,” but that we try to understand the context behind the stories. Of course, some of them should never have happened. But if the thrust of the article had been on proper reimbursement for the care of uninsured immigrants, I would have been happier with the story.

I want to see arguments from a single moral principle, the stewardship of scarce resources, for the right and good resolutions in these cases. How attenuated does “justice” become before it snaps—and is no longer justice?

What do you think? Click here to comment and view other responses.

Brain Death - Social Convention or Biologic Fact?

John Lantos, MD
November 14, 2008

The controversy at Children’s National Medical Center in Washington, DC over the treatment of a child with no detectable brain activity highlights the ambiguities surrounding the concept of brain death.

The concept of brain death came into existence in the late 1968 when an ad hoc group of Harvard professors published a paper in the Journal of the American Medical Association
entitled “A definition of irreversible coma.” The goal of the Harvard group was to define clinical criteria that doctors could use in order to determine that a patient had experienced irreversible cessation of brain function.

Over the next decade, all states adopted the concept of “brain death” as a new way of determining that someone was no longer alive. The primary purpose of brain death criteria was to facilitate the recovery of organs for transplantation. A secondary purpose was to help families make decisions about the withdrawal of mechanical ventilation.

There has always been confusion and disagreement about whether people who meet the neurologic criteria for brain death are “really” dead. There are clearly physiologic differences between patients who are brain dead and patients whose hearts have stopped.

Brain dead patients are still warm and pink. Their hearts beat. They maintain their blood pressure. They make urine. They can gestate babies. Their state of “deadness” is a social convention that allows certain things to be done to them that cannot be done to living people and that limits their rights to certain things to which living people have rights.

But what should we do in the cases involving people who do not accept the consensus? The clash is one of fundamental moral beliefs. For one side to win, the other side must lose. There is, unfortunately, no compromise position here. Either the ventilator will be turned off or it will be left on.

Because I believe that brain death is a social consensus, rather than a biologic fact, I think that parents have the right to make the decision about whether to authorize removal of the ventilator.
Because I believe that health care workers should not be forced to violate their conscientious beliefs, I believe that they have the right to refuse to participate in such a medical project.

For utilitarian reasons, I think society can decide whether or not to pay for such care.

Thus, I believe that, if the parents really want to continue mechanical ventilation, they should learn to do it themselves, at home, and should pay for it themselves. Few parents can do that.

Thus, pragmatically, I think the judge should allow the hospital to turn off the ventilator and let cessation of bodily function follow, as it inevitably will, cessation of brain function.

What do you think? To view and to contribute comments, click here.

Links:

Judge Delays Decision on Removing Life Support, Washington Post, November 11
Medical Advances Complicate Definition of Death, National Public Radio, November 11
CNMC v. Brody - Reasons to Stop Treatment, Medical Futility Blog, November 11

Can we build a just, two-tiered healthcare system?

Note: this week's post comes in the form of a news release from the Center for Practical Bioethics. Dr. John Lantos shares his thoughts on the prospects for healthcare reform given the history of the past 16 years on this issue.

What do you think? Please share your comments by clicking here.

President-elect Barack Obama has promised to provide health insurance for every child in America. How will that be achieved? If recent history is instructive, it will not be by creating a single, egalitarian system.

Instead, we will create a two-tiered system – a publicly funded safety net for the poor and a private market in health insurance for those who can afford it. That’s according to John Lantos, MD, author of a commentary on the issue in October’s Archives of Pediatrics & Adolescent Medicine.

In the commentary entitled “Four Recent Health Reform Initiatives: Implications for Pediatric Health Reform,” Dr. Lantos explored four national programs proposed since 1993 to expand services to children. Two passed and two failed. Every case featured a battle between public and private coverage.

The lesson of our recent political history is that “we create public safety nets for the poor and private markets for everyone else,” says Dr. Lantos. “Oddly, we maintain private markets even if they are no better than public systems and cost much more.”

Dr. Lantos is the John B. Francis Chair in Bioethics at the Center for Practical Bioethics and also served on the Task Force on National Health Care Reform chaired by then First Lady Hillary Clinton in the early 1990s.

The good news, according to Dr. Lantos, is that the infrastructure for a combined public-private program is already in place. Dr. Lantos says such a program would start with an expansion and redesign of federally qualified health centers (FQHC). Such changes would include:

1. An expansion of the grant-funded portions of each FQHC operating budget while also eliminating means testing so all children would be eligible.

2. Competition between free FQHCs and the private system. FQHCs would remain a bare bones operation required to maintain access and quality to ensure funding. The private system would be forced to improve to attract paying clients.

3. A free flow of professional labor between the two systems. If the public system expanded, there would be a need for more pediatricians.

FQHCs could provide primary care and some specialty care for millions of children, even if the children don’t have health insurance.

Dr. Lantos says this may not be so bad. “Primary care for children is not the sort of health service for which health insurance was invented,” he says. “It is not, after all, a rare and unforeseeable event. It is, instead, something all children need.”

Health insurance will still be necessary for specialty care or catastrophic illness. “Routine elements of well-child care are particularly ill-suited to the indemnity insurance model of financing,” he says. “Catastrophic health insurance would be the primary payor for inpatient care.”

“Such a system might harness our deeply ingrained political values,” Dr. Lantos concluded, “in a way that creates an adequate safety net for the poor, an efficient public-private partnership and a vibrant, competitive marketplace for different styles of pediatric care.”

Link: Four Recent Health Reform Initiatives: Implications for Pediatric Health Reform, John D. Lantos, MD, abstract, Archives of Pediatrics & Adolescent Medicine, October 2008