Wednesday, December 7, 2011

Physicians don't die like we do

Instead they shun the expensive, intrusive, costly, and futile end-of-life-care they give to the rest of us:

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
Link.   HT:

1 comment:

  1. Luke,

    Thanks for the great read. As a former oncologist, and internist, I lived this life. I am proud to say that only one person in an entire year – a young woman with Hodgkin's disease – died in a hospital trying to do "everything." But as the author says, it takes time. And physician families have enough sense to know of the insanity.

    As an intern, we had a lot of "out of town heroes." These are people who sometimes hadn't seen their relative for years but screamed "do everything or I'll sue you." Foolish trainee that I was, I often implied that doing everything might cost the estate and cut into whatever inheritance they had. Amazing how quickly they said "make her comfortable."

    I also spent a lot of time asking patients hard questions about bone marrow transplants back when their mortality was > 50%. In a sort of decision-analytic way, they'd say that the expected utility was higher by trying it. But they didn't factor their estates into account. Further, when transplant patients would relapse and be offered a second transplant (again, 20 years ago), every older patient would say "no way."

    Our mantra was: We can't make you live longer, but with enough money and chemotherapy, we can make it seem like a lot longer time. (And not in a positive way).

    Yes…docs – and their families – know. Everyone wants to do the right thing, but between the cognitive bias and the skewed incentives, it is as difficult to envision how difficult this can be as it is to envision a lot of other very real but abstract threats. It's along the lines of "next time it will be different" or "I know I'll be the lucky 5%." And it is in a sense little different from the perception of any Medicare beneficiary who expects high-cost interventions even if the QALYs and medical risks would suggest avoidance.

    This is what makes your work so important. Looking at the economics from the stark realities of theory and behavior. My question: what is the curve like for these decision? How price sensitive must a family be to impact their judgement? How does one help people understand this.

    Thanks again