This interview with physician Sherwin Nuland was very thoughtful and IMO is a prudent approach to the uncomfortable subject of managing end-of-life care decisions. I know medicine and death are very personal and emotional subjects, but I think if we dispassionately put the patient's best interests first and keep expectations reasonable, everyone will end up happier (especially the deceased) and society can save a lot of health care resources.
One issue that the doc didn't cover in the interview was assisted suicide, which has few rational arguments against it, and is becoming more accepted nationwide - similar to legal pot and gay marriage.
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Also heard something about end-of-life care on NPR the other day. There was a particular city that had a big promotion of advanced medical directives. What they found was that, as a result, medical costs went down quite a bit in their city. Apparently when people make a positive choice about the type of life they consider worth living it is significantly less expensive than the care legally mandated in the absence of a positive choice.
The major roadblock to those advanced directives is human
effort and human emotion. Understandable and probably not an
incredibly high hurdle to overcome.
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Agreed. More and more people are preferring to die relatively peacefully at home or hospice rather than "keep fighting" to the end with all the tubes and drugs in them at County General. And the irony is that the former group tends to last longer, and with less grief on themselves and the family, than the latter (obviously at much lower cost too as you said).
There are plenty of war stories where the stubborn commander refused to face reality and sentenced himself and his men to preventable death. Even worse, a stupid, egomaniac dictator doesn't understand opportunity cost, ignores his generals' pleas, and keeps throwing finite resources at an unwinnable battle, which ironically contributes to losing the overall war - see Stalingrad or Guadalcanal. We tend to mock those men and use their folly as teachable moments. So why can't we apply the same logic to medicine? Unfortunately there is such a thing as a no-win scenario, so the sooner we come to terms with that, the better it is for everyone. Would you gamble your life savings on 1 play at 1/1000 odds at the casino? Of course not - so why do we do it at the hospital? Is it because of moral hazard, or the finality/unknown nature of death?
On a personal note, what I really hate to see are relatives pressuring the dying person to "keep fighting" and "not let the disease win". It gives the false impression that the outcome is mostly in the patient's control, and it's a matter of effort/will. The patient has enough to worry about without that guilt. No one wants to be reminded that they are the source of the everyone's sadness, like it's their fault. Families may bring up outliers like Lance Armstrong, but forget that 99.99% of folks like Lance didn't make it. I'm not saying to abandon all hope, but at least don't impose ludicrous expectations. Unfortunately, the next of kin can get pretty selfish and they may not be ready to let go. But during these tough times, the best thing they can do is show as much comfort and compassion as possible for the dying.
But if it's the patient insisting on exhausting every medical possibility no matter the odds or costs, I am not sure how a physician or relative can/should dissuade them respectfully.
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