No surprise, but this 60 Minutes report way oversimplified—and I think misled—about the very real problem of the costs of end of life care, with supposedly too many people dying in ICUs:
- First, the economics of hospital payments by Medicare promote earlier releases. This is because hospitals are paid on a capitated basis by Medicare (the diagnosis related group system), which is why so much emphasis is placed by hospitals on “discharge management.” As a consequence, some patients and doctors worry about patients being released “sooner and sicker.” Yes, doctors are paid to consult, but the program should have mentioned hospital compensation that uses economics to reduce length of hospitalization. Indeed, hospitals lose money if a patient remains in hospital beyond the average stay for their condition.
- A lot of people who die in ICUs are not necessarily terminally ill. Doctors often don’t know whether someone is going to die, which is why such treatment is rendered. Indeed, the initial patient discussed in the report wasn’t dying from an illness and being kept alive despite her condition, but was unconscious due to complications of treatment coupled with a hospital acquired infection.
- Third, when a heart patient says he wants CPR, Dr. Ira Byock—who I know, like, and greatly admire for his work in hospice—says, “It wouldn’t be my choice.” But it should be the patient’s choice. (Also note, the patient later died without CPR because his family acknowledged how poor his condition became.)
- Yes, inappropriate tests are sometimes done—example, a pap smear for a dying octogenarian—but that can be remedied without draconian rationing and refusing efficacious approaches based on quality of life value judgments made by a physician or bioethics committee.
- Rationing is definitely on the agenda—and I think, a major purpose of the report: Byock promotes withholding “defibrillators” from certain patients based on their age and function, but bristles when Steven Croft says that “is pulling Grandma off the machine.” But then he couples that issue with the number of uninsured. Doctors cannot represent both societal interests and fulfill their fiduciary duties to individual patients. Indeed, whether Byock likes it or not, he is promoting rationing, and that means, by definition, not providing some patients efficacious treatments based on subjective quality of life judgments.
I agree completely with Byock that doctors need to do a much better job of educating terminally ill patients about their care options and exploring the many benefits of hospice. (The new health care law reduces budgets for this!) But the last thing the American people will (or should) stand for, is coercion. Nothing could sow greater distrust in medicine.
