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Unlikely Way to Cut Hospital Costs: Comfort the Dying
Wall Street Journal On-Line ^ | 10 March 2004 | GAUTAM NAIK

Posted on 03/10/2004 7:39:51 AM PST by shrinkermd

Edited on 04/22/2004 11:51:14 PM PDT by Jim Robinson. [history]

RICHMOND, Va. -- The palliative-care unit at Virginia Commonwealth University Medical Center offers plush carpeting, original watercolors and a kitchen for visiting families. A massage therapist drops by often, and a chaplain is available 24 hours. And there's High Anxiety, a fluffy white Lhasa apso that patients love to pet.


(Excerpt) Read more at online.wsj.com ...


TOPICS: Business/Economy; Culture/Society; Editorial; Unclassified
KEYWORDS: cancer; costsaving; healthcare; palliative
I feel uneasy about this article. First, while one can play statistical odds and tell a seriously ill patient there is no treatment, that is not what the patient wants. Most patients within reason want every effort to preserve life.

Second, I have a direct experience in respect to "palliative treatment." After many years of periodic smoking I developed chest pain with excertion. Prior to a stress echocardiogram a chest x-ray was done. It revealed (even I could read the film) a cancer of the left lung. I was told, by my old friend doctor, that the person doing biopsies was unlikely to perform the biopsy since the cardiologist (a different doctor) felt I also had heart disease. Of course this was a problem for me since I had no other symptoms, no echo cardiogram stress test and so forth.

Reluctantly, I went to the University of Minnesota. A biopsy was done within 24 hours: within 2 days I began receiving a host of traditional and experimental chemotherapies in a study that combined these with radiation. The study as implemented was sufficiently controversial that I paid for all the treatments that had a cost assigned to them.

I became so ill, required transfusions and contemplated that the "palliative care" recommended by my old friend as well as the cardiologist might have been right. That was two years ago. Yesterday my chest x-ray continued negative and while I can't say I am cured, I can say they can't find the cancer even though I receive a total body scan every six months.

The point of all this, is that medicine is by no means a certain science and even people declared hopeless respond to a great or lesser degree to prescribed treatments.

1 posted on 03/10/2004 7:39:51 AM PST by shrinkermd
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To: shrinkermd
Right now my father is in hospice. He's had to learn that you don't call 911 every time he can't breath, or each time he slips to the floor. Each time they would haul him to the hospital and give him blood, antibiotics, and generally beat him up, shape him up, and ship him home for a few weeks until the next incident.

Hospice has been a godsend, really.

However, to reach this point, his doc has had him on about 22 medications per day, SIX OF THEM ANTI-PSYCHOTIC type medicines. Each medicine has a side effect and when that side effect becomes unbearable, the doc gives him another pill for the side effect. Now that he's on hospice, I've asked the doc to get rid of some of the meds. He says they are all necessary. Dad's ending his life in a fog and it's sickening.

I'm all for palliative care. It's wonderful you got better, but everyone's different. There is no one-side-fits-all. Only YOU know what's best for you.

So many people are treated and treated and treated, and they end their lives being tortured to death. How much better to let the body slow down naturally, be kept pain free, and gently slip into the hereafter with loved ones around than poked and prodded, and filled with chemicals.

There is no one size fits all and no one lives forever. It's time this country quit turning its back on dying, accept that it's inevitable for all of us, and make it a positive experience, not only for the dying, but their loved ones.
2 posted on 03/10/2004 7:58:26 AM PST by Auntie Mame (Why not go out on a limb, isn't that where the fruit is?)
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To: Auntie Mame
My mother just passed this Friday. What was concerning to me was that UNTIL the patient is under Hospice care, the standard orders for pain medication will NOT be administered unless approved by her Doctor.

This creates a "gap" in patient care. The time from when the doctor says that there are no other procedures that they can administer (declaration of terminal) to when Hospice "receives" the patient.

It was during this time my mother regained awareness and was in considerable pain late at night. However, the on call physician would not administer pain medication as it would likely end her life. BTW, she had already agreed to a DNR order but since she was not under Hospice care, the on call was legally prohibited from doing anything because a lack of a living will.

Thankfully, the pain was short and my mother slipped into a coma before the end so all in all it was as little pain as possible.

It is a shame that lawyers and lawsuits have created an environment where people suffer because the right paperwork has not been completed. I'm of the opinion that the law should be changed so that once a person has been declared terminal, then the rule of thumb should first be comfort - not saving --- UNLESS the patient has designated that they want extraordinary measures taken. Sort of back wards from the way things are now.
3 posted on 03/10/2004 8:15:33 AM PST by taxcontrol (People are entitled to their opinion - no matter how wrong it is.)
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To: shrinkermd
My experience was a bit different than yours. When my father was diagnosed with metastatic lymphoma, I suspect that he had known for a while without telling anyone. A proud, dignified man, he waited in order to maintain as much control as possible. By the time it was obvious, the CA had gone beyond the expected reach of medicine.

Dad had said pointedly: No Life Sustaining Proceedures. No chemo, no radiation, no surgery.

The parade of specialists began, each one assuring me that "radiation will make him feel better" or other such rot. They simply couldn't accept the fact that Dad was ready and didn't want to be a guinea pig. He wanted to be comfortable and die in peace.

The Hospice RNs on the third floor understood completely. And therein hangs the tale, eh?

4 posted on 03/10/2004 8:34:18 AM PST by doberville (Angels can fly when they take themselves lightly)
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To: shrinkermd
The problem becomes that in an environment of socialized medicine, you wouldn't have been permitted to pay for any of the treatments that had a cost assigned to them, and they would have shuffled you off promptly to the hospice for "the benefit of society."

This is why we must work vigorously to make sure that Hillarycare never again sees the light of day in any form.
5 posted on 03/10/2004 8:40:50 AM PST by mvpel (Michael Pelletier)
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To: doberville
I've started writing a book about palliative care--or comfort care, as my hospital calls it.

It's my belief that we often don't look at the reality of our own death, how we will die, what do we want to happen or not happen, until it's too late to have much say...

I took a good look at the prospect of my own death--though it's impossible to know what will be the proximate cause, I do know that I will die, and that very likely more than half of my life is over. Hub and I have talked a lot about it, and we both know what the other wants, as do our children and siblings and doctors and priests.

Comfort care is a wonderful part of nursing, I am proud to have given it, and I hope to receive it some day. I've become close to many families, during the course of my career, and I value that so much...one of the most powerful tools I have is my acknowledgement that I do not know what the future holds for me, or how I will die, but that I want my patients to have all my best...and anything they want that's in my power.
6 posted on 03/10/2004 8:50:58 AM PST by Judith Anne (Is life a paradox? Well, yes and no...)
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To: Mrs Zip
ping
7 posted on 03/10/2004 8:56:20 AM PST by zip
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To: Auntie Mame
Dad's ending his life in a fog and it's sickening.

I know what you mean, my mom's last 3 or 4 weeks was one where she was coherent only at irregular intervals because of the pain medication but she was in too much pain to with hold them. Her last few days were spent without really knowing what was going on.

8 posted on 03/10/2004 9:15:24 AM PST by Blood of Tyrants (Even if the government took all your earnings, you wouldn’t be, in its eyes, a slave.)
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To: shrinkermd
"where many doctors prefer to use the latest technology or drug to prolong a patient's life"

I believe this is totally false...

while there may be a few docs that want to try everything, generally, most do not want to do that at all...

mostly, its the families of these patients....

whether its out of a false guilt or perhaps they think they are SO caring for their sick ones, that THEY will demand every thing be done, no matter what..

most docs and most nurses are sick to have to put feeding tubes into people that just want to be left alone, and the worse part is, you often have to STRAP their hands down so they don't pull out or even dislodge the feeding tube , because even slightly pulling it out can mean a horrible death from aspiration pneumonia....

Get this:.... no one has to accept any treatment whatsoever, no one...

You can change your living will at any time, in any circumstance...

The patient never has to have anything done...

but remember this, unless you get it in writing , don't expect even loving relatives to follow your wishes...

the power over a person's life really goes to some people's head, and they think that they can demand all sorts of treatment for their "loved one"....sad...and often their are bitter quarrels within families....some kids not wanting this be done, and others wanting it all....it makes for a horrible situation.....

9 posted on 03/10/2004 9:28:30 AM PST by cherry
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To: doberville
"each one assuring me that "radiation will make him feel better" or other such rot"

Isn't it mandatory for doctors to present every option available?....yes it is...

IF they don't , they get sued....happens everyday....

and besides, as someone mentioned above, sometimes going full tilt into a treatment can help...

Doctors can't win.....we sue them if they don't tell us about plan A, B, and plan C.....and then, OTOH...we get mad if they do.....

responsiblilty has to be on the shoulders of the patient and the family....

10 posted on 03/10/2004 9:37:25 AM PST by cherry
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To: Blood of Tyrants
Our grandparents knew about death....they grew up with it....

they witnessed their grandparents dying a death at home, with all the family around....

they witnessed both birth and death and grew to understand the cycle of life....

maybe most of us have gotten too "modern" to understand the importance and the naturalness of both being born, and of DYING....

Dying , btw, is not always just so quiet and slick....sometimes it can be agnozing to watch....

sometimes people breathe very hard, congested, straining for breath, or jittery, shaky, incoherent...restless and agitated...

again...in by gone days, people accepted death to be this way....

now....we all think that dying should just be quick and quiet with no fuss....

11 posted on 03/10/2004 9:45:43 AM PST by cherry
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later
12 posted on 03/10/2004 9:48:42 AM PST by independentmind
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To: shrinkermd
I agree with you that this system could (and probably would) be abused, however I'm all for easing the pain of the last few days/months. I've seen sying men on vent. and I know how much a moist Q-tip can ease their suffering. Hospital staff are just too busy and a ward that was dedicated to easing pain would be a welcome relief for many. I'm not afraid of dying, I'm just concerned about the trip!
13 posted on 03/10/2004 10:31:47 AM PST by Marie (My coffee cup is waaaaay too small to deal with this day.)
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To: cherry
Dying is UNNATURAL. Every living thing has an innated desire to continue living.
14 posted on 03/10/2004 11:29:56 AM PST by Blood of Tyrants (Even if the government took all your earnings, you wouldn’t be, in its eyes, a slave.)
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To: Auntie Mame
I didn't think this was new...when my Dad was in his final weeks they gave us the choice. If we went the Hospice way, where he could come home, he would sign away any right to lifesaving treatment. They gave him drugs to make sure he was in NO pain and alot of nursing care and he died in peace. I didn't realize this wasn't done everywhere.
15 posted on 03/10/2004 11:33:45 AM PST by Hildy (A kiss is the unborn child knocking at the door.)
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To: cherry
I'm afraid that I wasn't clear. We were up front and very pointed in telling the Docs that extraodinary measures and life extending proceedures had been considered and rejected.

As you said, it it their job to offer every possibility. And they did.

Sometimes, however, some are resigned to the inevitable and don't want to extend the grieving and expense to those nearest. This was one such case. The Doctors just didn't seem to understand his rational or motivation. It simply made coping more difficult.

16 posted on 03/10/2004 5:14:21 PM PST by doberville (Angels can fly when they take themselves lightly)
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To: taxcontrol
I'm so sorry to hear of the loss of your mother. I can't even imagine life without my mom.

One of the things the hospice social worker told me that was interesting (horrible, actually), was that when she first went into this line of work, about 15 years ago, the LAW said that when an elderly patient lost a certain percentage of weight, they were automatically tube fed whether they wanted it or not. She said one of her first traumatic experiences in the field was going into a nursing home and seeing all these old people lying in beds lining the "wards" with tubes going into their stomachs. It was the law.

Since that time the government has found that it's far less expensive to let people's bodies wind down naturally. It's perfectly natural at the end of life to not want to eat or drink. Thankfully, no longer do we torture those who are winding down their days.
17 posted on 03/10/2004 7:02:45 PM PST by Auntie Mame (Why not go out on a limb, isn't that where the fruit is?)
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To: Hildy
Hildy, when a hospital gets hold of you, their job, their reason for existence, is to save lives. So, they give the patient whatever it takes to save their lives. In my dad's case they have a patient that has multiple problems, many of which are undiagnosed because to truly diagnose the problems they'd kill the patient. The medical name for these type patients is "trainwrecks."

In the old days, these people would be warehoused in nursing homes (and tube fed). It's only been recently that hospice care has become common in this country and from what I've seen, it's truly a blessing.

I'm sure in hospice care there will and have been some people who, with heroic efforts, could have been "saved" for a few more weeks, months, maybe even years (although one might wonder about their quality of life). Everyone, though, should have the choice--comfort care, or heroic medical efforts.

I'm so glad your dad could die at home, painfree and with his family around him. Which brings up one other point: We've got to consider the family. Do they want to remember their loved one lying in bed, being able to stroke their arm, feed them, helping them be comfortable, just being together with their whole family during those precious moments, or do they want to remember walking into a hospital room and seeing a cold body with tubes and needles inserted into a basically lifeless body?
18 posted on 03/10/2004 7:22:52 PM PST by Auntie Mame (Why not go out on a limb, isn't that where the fruit is?)
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To: Marie
Hello, and please excuse me for being intrusive, but please explain about the moist Q-Tip. How would it be used? How does it help? Thank you.
19 posted on 03/10/2004 9:09:20 PM PST by Museum Twenty (Support the President - wear the Baseball Cap - display the Bumper Sticker - http://www.ilovew.com .)
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To: GodBlessPeggyNoonan
Not a problem. When a person is on a vent. their mouth becomes painfully dry. You have to constantly moisten their mouth with a Q-tip to bring some relief. YOu have to be careful so no excess moisture drips down the throat and into the lungs, but it really does help. The pain of a dried-out mouth, tongue and lips is constant and unbearable. The patient can be well-hydrated via IV and still be miserable with cracked and bleeding lips and terrible dry mouth. It's one of those things that doesn't threaten your life, but will make you want to die. Pure torture. After my grandfather recovered enough to get off the vent, all he could do is tearfully thank my mother for keeping his mouth moist for the week he was in the ICU. He said that the pain of the dry mouth was worse than the illness that put him in the hospital in the first place.
20 posted on 03/10/2004 10:31:43 PM PST by Marie (My coffee cup is waaaaay too small to deal with this day.)
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