End of Life Decisions

[Awesome Sauceome]

Having worked at a nursing home, its terrible to see that problems with end of life care are endemic to the entire system. This is truly heart wrenching.

http://www.nytimes.com/2014/09/26/n...-to-die-at-home.html?partner=rss&emc=rss&_r=0

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[iWillOneDay]

It's all a business now. I wonder if it was ever not a business.

 

[Zelda840]

So sad.

 

[primadonna22274]

This was one of the worst and most poignantly written stories I've read on EOL care in America. We're doing it all wrong.

 

[desdes]

very sad

 

[costales]

Common sense is becoming rarer each day in our society. The profiteers and their lawyers have taken over.

 

[Awesome Sauceome]

I wonder what sorts of things in our culture will change so as we will be able to catch up with the rest of the 1st world healthcare wise. How can we spend such an exorbitant amount of money and yet still have such high rates of mortality, and such low rates of satisfaction with the system.

I think if/when insurance companies lose their grip on society then things will be a lot better off. You have insurance companies telling physicians how they can practice, telling hospitals who they can take in and what they can do, and then deciding what medications, treatments, as well as life and death for patients. Literally no one is in control of the healthcare system in this country, except for insurance companies. Yet it seems like most laymen that I know will be quick to blame a doctor or quick to blame a hospital. All the while the insurance companies keep leading this country's health into the ground and making fat stacks.

I am obviously concerned about issues with a single payer/government system as lots of people are. But there has to be some middle ground here... How can outside government or corporate entities have so much influence on your fate?

 

[ananasmed]

This article made me cry when I read it last night after my shift as a CNA

 

[doreegon]

As Americans we have the most expensive health care system in the world, and it makes a small group of people fabulously rich and powerful.

 

[SOOyC52H1Sof]

I talked about this in my PS

 

[sopyretuen]

yes,Common sense is becoming rarer each day in our society. The profiteers and their lawyers have taken over.

thanks

 

[LA1004]

“The way the reimbursement system works, these decisions are not made on the basis of what the individuals need. They’re based on what the institutions need.”
Ok, I get it that there are problems with the system. However, lets assume there is a doctor out there who truly gets to know his patients and wishes to fulfill the desire of the patient to die at home. Is it possible for him to do as requested by the patient or is his/her hands legally bound to send him to a nursing home? In essence, is it a legal problem or a "money, money, money!" problem?

 

[Awesome Sauceome]

“The way the reimbursement system works, these decisions are not made on the basis of what the individuals need. They’re based on what the institutions need.”
Ok, I get it that there are problems with the system. However, lets assume there is a doctor out there who truly gets to know his patients and wishes to fulfill the desire of the patient to die at home. Is it possible for him to do as requested by the patient or is his/her hands legally bound to send him to a nursing home? In essence, is it a legal problem or a "money, money, money!" problem?

Its all insurance companies man... the insurance companies tell doctors how they can practice (seriously, its getting bad), they tell hospitals how they have to run, and they tell patients what their options are. Its not the docs fault nor necessarily the nursing home. Its the insurance companies.

Now the question of WHY our society and healthcare system lets insurance companies have so much power, is beyond me... I am not sure if a single payer system is necessarily the cure, but I do believe that healthcare is one area in society where capitalism should not apply. Because at its core companies will ALWAYS pick money over their patients health, it just is what it is.

 

[LA1004]

Its all insurance companies man... the insurance companies tell doctors how they can practice (seriously, its getting bad), they tell hospitals how they have to run, and they tell patients what their options are. Its not the docs fault nor necessarily the nursing home. Its the insurance companies.

Now the question of WHY our society and healthcare system lets insurance companies have so much power, is beyond me... I am not sure if a single payer system is necessarily the cure, but I do believe that healthcare is one area in society where capitalism should not apply. Because at its core companies will ALWAYS pick money over their patients health, it just is what it is.

Completely agree, Awesome. There must be a better way than Capitalism, because human lives are much more valuable than money. But the problem is too many of us just focus on the money that we will do anything to get it, even if it is at someone else's suffering.

Just finished the article. It's just sickening to read all of it! As a former CNA I cannot accept "Nursing Homes" not providing the basics of human decency to any person (cleanliness and food), let alone a WWII veteran who suffered more than we imagined fighting in the Pacific for a country now failing them. But like they say in Brazil, "O buraco é mais embaixo" (essentially, the hole is further down).

I want to go into Geriatrics, mainly because of a utopian view that "I can change the system!", but this is just too disheartening. If my hands are tied as a doctor, then what good can we really do to our patients?

 

[Omppu27]

Its all insurance companies man... the insurance companies tell doctors how they can practice (seriously, its getting bad), they tell hospitals how they have to run, and they tell patients what their options are. Its not the docs fault nor necessarily the nursing home. Its the insurance companies.

Now the question of WHY our society and healthcare system lets insurance companies have so much power, is beyond me... I am not sure if a single payer system is necessarily the cure, but I do believe that healthcare is one area in society where capitalism should not apply. Because at its core companies will ALWAYS pick money over their patients health, it just is what it is.

Due to the current structure of the healthcare system in the US, I don't think a single-payer system such as the ones in the UK is in the near future for the United States. It's just entirely too much of a change. There are, however, many other countries that have managed to deliver accessible, affordable care in ways similar to how most of the US receives it's care (see france and germany, for example).

I do think the ACA has helped take some of the power you're talking about away. Now that insurance companies can't deny patients for preexisting conditions, can't place lifetime caps, and must allow kids to stay on their parents' plans until they're 26, we've definitely taken a step forward.

Also, your original post comments on the struggles we have with EOL care. We can flip this around and look at the issues we have with just keeping out babies alive too... The infant mortality rate in parts of the US is third worldish.

 

[Awesome Sauceome]

Due to the current structure of the healthcare system in the US, I don't think a single-payer system such as the ones in the UK is in the near future for the United States. It's just entirely too much of a change. There are, however, many other countries that have managed to deliver accessible, affordable care in ways similar to how most of the US receives it's care (see france and germany, for example).

I do think the ACA has helped take some of the power you're talking about away. Now that insurance companies can't deny patients for preexisting conditions, can't place lifetime caps, and must allow kids to stay on their parents' plans until they're 26, we've definitely taken a step forward.

Also, your original post comments on the struggles we have with EOL care. We can flip this around and look at the issues we have with just keeping out babies alive too... The infant mortality rate in parts of the US is third worldish.

Exactly... I honestly dont know enough about other countries' healthcare systems to comment, other than the fact that I know many have found some sort of middle ground between a single payer system and complete capitalism. I also agree, while I think overall we are moving in the direction of a single payer system, it is far off. If you talk to physicians, a lot of them think it is coming though, its just a matter of time. It was one thing for insurance companies to hit hospitals, then it was another to hit docs, now things are really hurting patients... Basically the insurance companies have no one backing them except for the politicians that they are backing. Eventually this will change...

I totally agree... the fact that on a federal level, insurance companies were forced to change, for the betterment of US citizens is a big deal. I do not think the ACA is the cure to the healthcare problem in the US, in fact in some areas it made it worse I think, ESPECIALLY for physicians. I think physicians and small healthcare groups are going to bear the brunt of the burden for a while until things settle... However, it really did make a step in the right direction in controlling the outrageous control that insurance companies have on healthcare. I mean even looking back, it seems insane that an insurance company could just deny people for being sick. I mean logistically for them it makes sense, but it makes no sense when it comes to healthcare. If insurance companies are not willing to pick up the slack, then the US government WILL be the ones picking up the tab, which is bad. So its good that they took steps on on stuff like that.

Again, I completely agree... We are spending more money on healthcare in this country than some countries' entire GDP. Yet we have increasingly diminished returns and massive deficiencies depending on geography. Its crazy that our spending is number 1, but our quality is ridiculously low... last time I check we were in like 26th place or something for health metrics worldwide? I think the only thing that we really have going for us is medical research, which is still a major strong suit to this nation, and for that I am extremely proud. But when it comes to helping the common person, we are failing pretty badly.

But having said all that. I truly do believe that things will get better, I really do. In fact, I think a lot of people are bailing from the healthcare system simply because they are getting so frustrated with it. But in my mind its like "when there is blood in the streets, buy property." I think we are entering the field at a pretty horrible time, but I think when things start to mellow out, we will be sitting pretty well. The people who started practicing 20 years ago are miserable because they look back at the golden days when they had loads of freedom, time, and things were great. I think we will have the opposite effect; I think in 20 years we will be looking back and arguing how much better things have become. Now how we get from A to B is beyond me, but just historically, the healthcare system in this country tends to oscillate between being really bad (and making physicians unsatisfied) and being really great (and having very satisfied physicians). But who knows, I could be completely wrong... we shall see heh.

 

[cliquesh]

It isn't all that bad. You guys will be okay.

 

[Awesome Sauceome]

It isn't all that bad. You guys will be okay.

See things have gotten better overnight! I knew it I was right!

But seriously, thanks man. Some docs seem so miserable about the situation (mostly FM docs that I have run into), so its good to hear that its not as bad as people say. I have faith in it either way, I know that I am going down the right path regardless, 100%.

 

[LilEngineThatCould]

This is so sad. I really want to go into geriatrics because I love working with this population and this is what I dealt with working as a CNA in assisted livings and home healthcare, but it's sad to see how little power the doctors and patients have over decisions that should be theirs to make. The capitalism we love so much really hurts healthcare and I honestly wonder when it will finally end. Maybe never? Meh. I wanted to come in, become a doctor and change things for the better, but I've come to realize that without political and monetary power there really isn't much a single person can do. It's kind of depressing, but I just hope that I can make my patients as healthy and happy as I possibly can.

On a side-note I've looked up the health metrics rankings before and there are so-called "third-world" countries that apparently do their healthcare better than us lol

 

[LilEngineThatCould]

Just read the article in its entirety and I teared up. Terrible, terrible thing we have in our country and ppl expect you to be a proud American, when those who fought for this country can't even die with dignity and their last wishes fulfilled.

 

[Psychonergic]

My last visit to the nursing home in my community left me very upset. 3 sweet old ladies were begging my partner and I to take them away from there. It's definitely a quality of care issue.

 

[SUHospitalMD]

For any medical student interested in end of life care/palliative medicine, please check out the innovative Resident Palliative Care Education program offered at CPMC in San Francisco for internal medicine residents: http://wp.me/P6205D-1

Most residencies do not have a dedicated Palliative Care program for the residents, this one is great!

 

[MedBrah 19]

You guys should read "Being Mortal" by Atul Gawande. Good book on the subject.

 

[BklynRN]

The author Nina Bernstein is a big journalist in NYC who likes to write about Medicaid/Medicare and specifically NYS Medicaid Long Term Care. The problem with Ms. Bernstein is she does not have a good grasp on how long term care works and how long term care plans must operate by law in NY. I am a R.N. who works for a Medicaid long term care plan in NYC and before you get your pitch forks out maybe you should hear from the other side. People who are both dual Medi/Medi, who have both Medicaid and Medicare, they are the most at risk to need long term care and nursing home placement (and also eat up 30% of all medicaid spending in NY). In NY state now anybody who has a long term care need and has trouble doing ADL's/IADL's are required to join a Medicaid Managed Long Term Care Plan to get services, such as, home care, private duty nursing, PT, OT, dental, vision, podiatry, social day care etc etc etc. They must first have a nurse from the state come and say they are qualified to get LTC then they must pick a plan and the nurse from that plan will go out to say how may days of aide service they will roughly qualify for and then they can agree to joint that plan or another. The problem is we cannot give people what they want, we are budgeted for every patient that enrolls so for the 65 year old who just needs limited help we get 3600 a month and the completely bed bound client with Alzheimer's we get 3600. This is called capitation, the state gives the same amount for each member regardless of the extent of care.

Now the going rate to pay for someone to get 24-7 live in care- even though it says live in care we actually pay 13 hours a day $18 a hour- comes out to 85,410 dollars a year..... that is just the home care-- factor in the cost of their supplies, the cost of paying for their care management, the cost of their transportation and that easily brings it to 150,000 a year.... how are we suppose to adequately for this person when we only will receive 43,200 a year from the state for this person? When these services can be provided in a nursing home for 65,000 a year which is still expensive and over budget but we are required by law to provide a safe plan of care..... so my question is how would Mrs. Bernstein like us to possibly stay open to service all of our patients with those numbers?

 

[dynx]

Completely agree, Awesome. There must be a better way than Capitalism, because human lives are much more valuable than money. But the problem is too many of us just focus on the money that we will do anything to get it, even if it is at someone else's suffering.?

Exactly! All about the money!!!!
How much did she want to return him home?!?!? So bad she wanted someone else to pay for it!
But if she had to foot the bill for care or God forbid change a diaper herself at home? F*ck that, he can die in a nursing home while I bitch and moan. (At least in this case it seems she did something which is not normal)
There's a thing called AMA. You want to go home? Sign out AMA and ****ing leave. Oh! You want to go home and have someone else pay for it? I didn't realize that money was the most important thing. The insurance company wants to save money on a customer they don't even know and they're evil. A family member refuses to foot the bill to fill the dying wish of someone they've known all their life and THEY are the victim? Get the hell out.
insurance isn't an open menu. It covers certain things. You won't die in a gutter, you won't die without pain medication. You want to die at a specific address? Well, maybe your family should suck up their **** and put up some money if they think money doesn't matter. But when it's their cash all of a sudden well...you know...I have other obligations, have to work this and that...oh! You mean you have a f*cking budget just like the insurance company? Well I'll be goddamn! I guess money does matter!
I've been on both ends. We put my dad in a private plane so he could die at home. At the time I wasn't exactly doing well but you know, the guy changed my diapers and looked out for me my entire life. I've seen families "so concerned" about where their parent ends up till they find out that "oh no!!!! I'm going to be out of pocket 5k!!!!" Well now, I'm a little less concerned, after all he'll be dead soon and we can complain about the evil of corporate medicine. Double bonus!!!

 

[BklynRN]

Exactly! All about the money!!!!
How much did she want to return him home?!?!? So bad she wanted someone else to pay for it!
But if she had to foot the bill for care or God forbid change a diaper herself at home? F*ck that, he can die in a nursing home while I bitch and moan. (At least in this case it seems she did something which is not normal)
There's a thing called AMA. You want to go home? Sign out AMA and ****ing leave. Oh! You want to go home and have someone else pay for it? I didn't realize that money was the most important thing. The insurance company wants to save money on a customer they don't even know and they're evil. A family member refuses to foot the bill to fill the dying wish of someone they've known all their life and THEY are the victim? Get the hell out.
insurance isn't an open menu. It covers certain things. You won't die in a gutter, you won't die without pain medication. You want to die at a specific address? Well, maybe your family should suck up their **** and put up some money if they think money doesn't matter. But when it's their cash all of a sudden well...you know...I have other obligations, have to work this and that...oh! You mean you have a f*cking budget just like the insurance company? Well I'll be goddamn! I guess money does matter!
I've been on both ends. We put my dad in a private plane so he could die at home. At the time I wasn't exactly doing well but you know, the guy changed my diapers and looked out for me my entire life. I've seen families "so concerned" about where their parent ends up till they find out that "oh no!!!! I'm going to be out of pocket 5k!!!!" Well now, I'm a little less concerned, after all he'll be dead soon and we can complain about the evil of corporate medicine. Double bonus!!!

Yes, this exactly my point. They have such great expectations, but want either Medicare or Medicaid to foot the bill. If more cost was shared by loved ones they will instantly change their opinions about what realistic decisions need to be made.

And, this man should've have been in hospice a long long time ago. He would not have suffered such great breaks in continuity of care if families were honestly talk to about his situation. Not at home hospice but inpatient hospice.

 

[Neuronix]

SDN is a professional forum for professional debates. The filters for language are not there to be used. Please no **** or swear words with just one letter *ed out.

 

[Wallky]

This is very sad.