CBS: The Cost of Dying
Patients' Last Two Months of Life Cost Medicare $50 Billion Last Year; Is There a Better Way?
(CBS) Every medical study ever conducted has concluded that 100 percent of all Americans will eventually die. This comes as no great surprise, but the amount of money being spent at the very end of people's lives probably will.
Last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives - that's more than the budget of the Department of Homeland Security or the Department of Education.
And it has been estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.
You might think this would be an obvious thing for Congress and the president to address as they try to reform health care. But what used to be a bipartisan issue has become a politically explosive one - a perfect example of the costs that threaten to bankrupt the country and how hard it's going to be to rein them in.
Marcia Klish is either being saved by medical technology or being prevented from dying a natural death.
She is 71 years old and suffering from the complications of colon surgery and a hospital-acquired infection. She has been unconscious in the intensive care unit at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., for the better part of a week.
One of her doctors, Ira Byock, told 60 Minutes correspondent Steve Kroft it costs up to $10,000 a day to maintain someone in the intensive care unit. Some patients remain here for weeks or even months; one has been in the ICU since May.
"This is the way so many Americans die. Something like 18 to 20 percent of Americans spend their last days in an ICU," Byock told Kroft. "And, you know, it's extremely expensive. It's uncomfortable. Many times they have to be sedated so that they don't reflexively pull out a tube, or sometimes their hands are restrained. This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die."
Dr. Byock leads a team that treats and counsels patients with advanced illnesses.
He says modern medicine has become so good at keeping the terminally ill alive by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily.
"Families cannot imagine there could be anything worse than their loved one dying. But in fact, there are things worse. Most generally, it's having someone you love die badly," Byock said.
Asked what he means by "die badly," Byock told Kroft, "Dying suffering. Dying connected to machines. I mean, denial of death at some point becomes a delusion, and we start acting in ways that make no sense whatsoever. And I think that's collectively what we're doing."
A vast majority of Americans say they want to die at home, but 75 percent die in a hospital or a nursing home.
"How do so many people end up in the hospital?" Kroft asked Dr. Elliott Fisher, a researcher at the Dartmouth Institute for Health Policy.
"It's the path of least resistance," Fisher said.
The institute did a detailed analysis of Medicare records for patients in the last two years of their lives. Fisher says it is more efficient for doctors to manage patients who are seriously ill in a hospital situation, and there are other incentives that affect the cost and the care patients receive. Among them: the fact that most doctors get paid based on the number of patients that they see, and most hospitals get paid for the patients they admit.
"The way we set up the system right now, primary care physicians don't have time to spend an hour with you, see how you respond, if they wanted to adjust your medication," Fisher said. "So, the easiest thing for everybody up the stream is to admit you to the hospital. I think 30 percent of hospital stays in the United States are probably unnecessary given what our research looks like."
And once someone is admitted to the hospital, Fisher says, they're likely to be seen by a dozen or more specialists who will conduct all kinds of tests, whether they're absolutely essential or not.
Meredith Snedeker's 85-year-old mother spent her last two months shuttling between a nursing home and community hospital in New Jersey, suffering from advanced heart and liver disease.
Dorothy Glas was a former nurse who had signed a living will expressing her wishes that no extraordinary measures be taken to keep her alive. But that didn't stop a legion of doctors from conducting batteries of tests.
"I can't tell you all the tests they took. But I do know that she saw over 13 specialists," Snedeker told Kroft.
Asked what kind of specialists, Snedeker said, "Neurological, gastroenterologists. She even saw a psychiatrist because they said she was depressed. And she told the psychiatrist, 'Of course, I'm depressed. I'm dying.'"
When we reviewed the medical records, we discovered that there weren't 13 specialists who attended to her mother: there were 25, each of whom billed Medicare separately.
The hospital told 60 Minutes that all the tests were appropriate, and an independent physician said this case was fairly typical.
"You think they were running up the bill to make money? Or running up the bill or giving her all these tests because they really thought it might help her? Or to cover their…rear?" Kroft asked.
"Yeah, to cover their rear," Snedeker replied.
Among the tests conducted was a pap smear, which is generally only recommended for much younger women, not an octogenarian who was already dying of liver and heart disease.
"In medicine we have turned the laws of supply and demand upside down," Elliot Fisher said. "Supply drives its own demand. If you're running a hospital, you have to keep that hospital full of paying patients. In order to, you know, to meet your payroll. In order to pay off your bonds."
"So, the more M.R.I. machines you have, the more people are gonna get M.R.I. tests?" Kroft asked.
"Absolutely," Fisher said.
"There are people that would argue this is great medicine. You get tested for every conceivable, possible malady you might have," Kroft pointed out.
"Often the best care is saying 'Let's see how you do on this particular treatment for a couple of days. And see if you respond.' Not necessarily doing a lot of tests," Fisher said. "The best care may well be staying home with a trial of a new medication, rather than being admitted to a hospital where you can be exposed to a hospital-acquired infection. We have a system that rewards much, much more care."
In almost every business, cost-conscious customers and consumers help keep prices down. But not with health care. That's because the customers and consumers who are receiving the care aren't the ones paying the bill.
"The perverse incentives that exist in our system are magnified at end of life," David Walker, the government's former top accountant told Kroft.
Walker used to be the head of the Government Accountability Office. He now heads the Peter G. Peterson Foundation, which is a strong advocate for reducing government debt. He says that 85 percent of the health care bills are paid by the government or private insurers, not by patients themselves. In fact most patients don't even look at the bills.
"Does that make any sense to have, I mean, most things you buy, the customer has some impact," Kroft remarked.
"We have a system where everybody wants as much as they can get, and they don't understand the true cost of what they're getting. The one thing that could bankrupt America is out of control health care costs. And if we don't get them under control, that's where we're headed," Walker said.
With end-of-life care, there are also delicate cultural and political considerations.
Patients, with their families' support, want to cling to life, and it is often easier to hope for a medical miracle than to discuss how they want to die.
Charlie Haggart is 68 years old and suffering from liver and kidney failure. He wants a double transplant, which would cost about $450,000. But doctors have told him he's currently too weak to be a candidate for the procedure.
At a meeting with Haggart's family and his doctors, Dr. Byock raised the awkward question of what should be done if he got worse and his heart or lungs were to give out.
He said that all of the available data showed that CPR very rarely works on someone in Haggart's condition, and that it could lead to a drawn out death in the ICU.
"Either way you decide, we will honor your choice, and that's the truth," Byock reassured Haggart. "Should we do CPR if your heart were to suddenly stop?"
"Yes," he replied.
"You'd be okay with being in the ICU again?" Byock asked.
"Yes," Haggart said.
"I know it's an awkward conversation," Byock said.
"It beats second place," Haggart joked, laughing.
"You don't think it makes any sense?" Kroft asked the doctor.
"It wouldn't be my choice. It's not what I advise people. At the present time, it's their right to request it. And Medicare pays for it," Byock said.
When it comes to expensive, hi-tech treatments with some potential to extend life, there are few limitations.
By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too.
"I think you cannot make these decisions on a case-by-case basis," Byock said. "It would be much easier for us to say 'We simply do not put defibrillators into people in this condition.' Meaning your age, your functional status, the ability to make full benefit of the defibrillator. Now that's going to outrage a lot of people."
"But you think that should happen?" Kroft asked.
"I think at some point it has to happen," Byock said.
"Well, this is a version then of pulling Grandma off the machine?" Kroft asked.
"You know, I have to say, I think that's offensive. I spend my life in the service of affirming life. I really do. To say we're gonna pull Grandma off the machine by not offering her liver transplant or her fourth cardiac bypass surgery or something is really just scurrilous. And it's certainly scurrilous when we have 46 million Americans who are uninsured," Byock said.
"Every other major industrialized nation but the United States has a budget for how much taxpayer funds are allocated to health care, because they've all recognized that you could bankrupt your country without it," David Walker told Kroft.
Asked if he is talking about rationing, Walker said, "Listen, we ration now. We just don't ration rationally. There's no question that there's gonna have to be some form of rationing. Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you're talking about taxpayer resources, there's a limit as to how much resources we have."
But if recent history is any guide, rationing has become the third rail of American politics, even though Elliot Fisher says we already limit health care based on income and whether people have insurance.
After analyzing Medicare records for end-of-life treatment, Fisher is convinced that there is so much waste in the present system that if it were eliminated there would be no need to ration beneficial care to anyone.
Multiple studies have concluded that most patients and their families are not even familiar with end-of-life options and things like living wills, home hospice and pain management.
"The real problem is that many of the patients that are being treated aggressively, if you ask them, they would prefer less aggressive care. They would prefer to be cared for at home. They'd prefer to go to hospice. If they were given a choice. But we don't adequately give them a choice," Fisher said.
"At some point, most doctors know that a patient's not likely to get better," Kroft remarked.
"Absolutely," Fisher agreed. "Sometimes there's a good conversation. Often there's not. You know, patients are left alone to sort of figure it out themselves."
That's what Meredith Snedeker says happened to her mother. Though she received $40,000 worth of care in her last two months of life, not one of her 25 doctors sat down with Dorothy Glas and her family and discussed how she wanted to die.
Marcia Klish might have lingered for quite some time in the intensive care unit at Dartmouth-Hitchcock Medical Center. But Dr. Byock and his team had a number of meetings with her closest friend, Barbara Menchin. She said Klish would not want to be kept alive on machines if there was no meaningful hope of recovery.
It was decided the doctors would not try to resuscitate her if her condition worsened, which it soon did.
"Her heart has just flipped into a rhythm that doesn't allow it to beat effectively," Byock told Menchin.
Klish died a few moments later.
"This is a hard time in human life. But it's just a part of life," Byock said.
"Collectively, as a culture, we really have to acknowledge that we're mortal," he said. "Get over it. And start looking at what a healthy, morally robust way for people to die looks like."
A final note:
After we finished this story, we received word that Charlie Haggart, the patient who was hoping for a liver and kidney transplant, died this week at a hospital in Vermont.
His brother said Haggart's condition had deteriorated so much the family decided that no attempts would be made to resuscitate him.
Web Extra: Comfort and Costs According to oncologist Letha Mills, whose 70-year-old husband Dr. Herb Maurer is terminally ill with cancer, helping people die at home might increase their comfort and create savings in our healthcare system.
Web Extra: At Home, At Peace Dr. Herb Maurer has made a decision about where he will spend his final days. (Additional footage courtesy of Adam Maurer and Chautauqua Films.)
⇒ Show All Comments - Originally from CBS Reader's Comments
by RonPanzer November 25, 2009 8:47 PM EST
What Dr. Byock and others are not telling you is that many patients are hastened to their death, i.e., death is imposed when they are not agitated, not even in the intensive care unit. Patients who have a terminal illness do not ask to be killed the moment they enter hospice and they do not wish to be sedated when they are not agitated. But physicians like Byock and Quill are pushing terminal sedation, the permanent sedation of patients until they die. They die because they are not getting fluids, even though they could be walking, talking, eating and drinking. People all over this country are having death imposed upon them by physicians and/or nurses who take it upon themselves to hasten death. Sometimes patients are outright overdosed with morphine and their breathing stops due to opioid overdose, suppression of the respiratory effort.
60 Minutes II did a story about such killings in hospice in their 1998 article, "A Question Of Homicide?" which detailed where 19 hospice deaths were ruled officially as homicides by the coroners and referred for prosecution to the DA, but which was covered up by a special panel of hospice doctors with ulterior motives that ruled all the 19 homicides as "natural deaths."
We at Hospice Patients Alliance hear about such imposed deaths regularly. How would you like it if your loved one was snuffed out in a hospice. Good hospice would never do this, but it is now widespread in the hospice industry. This is the reality Byock is not telling you about. He knows.
by sddesai November 25, 2009 4:24 PM EST
I am a primary care provider in Northwest Iowa. I entirely agree that death is inevitable and no one wants his or her loved ones to "die badly" in the ICU. WE need to deliver this message across the entire nation.The way to do it is to have HOSPICE conferences/lectures throughout the country to explain to the American people how to deal with the terminal illness and " to die with dignity and quality" instead of prolonging the dying process with pains and misery for everybody.
We had a HOSPICE conference in this region 2 months ago. About 400 people attended it.As a physician, I am already noticing some positive changes in how people think about the terminal illness and the process of dying.
by WalkerJK November 25, 2009 9:37 AM EST
I really think you need to do a segment on Hospice as opposed to extreme medical measures to keep an elderly (or younger) person alive. It would allow people to understand Hospice and to let people know what wonderful things they can do to allow Dignity at the End of Life.
My dad was put into Hospice last January, having been diagnosed with three types of cancer. Surprisingly, he is still with us. He has a "Comfort One" form he keeps in his apartment. It tells EMTs to not perform CPR or take any extreme measures if they are called. Mostly they have been called when he has fallen. He has then been checked out to make sure there are no broken bones and has mostly been able to come home to his apartment again.
My Mom was diagnosed with liver cancer at the end of June and died the end of August. During that time she was able to have her family around her and, until the last two weeks of her life, she enjoyed living life as she liked. The last two weeks we were able to keep her in her own apartment with minimal help for the nighttime shift. She was kept comfortable, and passed away calmly in the middle of the night in her own bed.
I can't say enough about Hospice and how wonderful they are.
by rlm807 November 24, 2009 10:09 PM EST
I wish people did not look at this from the family's perspective only. The doctors and hospital have responsibility as well. I watched the segment and felt as if you knew my family. My mother fell at home in April, went to rehab and was due to be released. A week before her release, she was found on the floor. Subsequently she was taken to a well know hospital, admitted into SICU. All her records noted there was DNR, living will, health care proxy etc. Not only did she have medicare, but supplimental insurance as well =btb, she was 90, had worked since she was 16, thus her medicare is what she paid into (she retired in her 80's)taking nothing that she did not pay into! 3 days in, she was moved to a surgical floor, in the middle of the night I heard my cellphone. Unfortunately, I did not get to it in time, the callback was restricted. The hospital had 5 other numbers for my family The next morn, we learned that she was back in SICU and intibated. Not only were we upset, but so was she.We have a strong belief that without quality of life, you have nothing. Moreover, her wishes were not honored. 2 days after the tubes were removed, she passed -both the first time and when she passed, she had distressed breathing. She was to be moved to pallitive care, but given she lived on her terms, she passed the same way. It was hard watching her suffering, she had not lost her mind, her body failed her though! Imagine having tubes you do not want in you because some doctor thought it was in her best interest,my belief, they did not properly read her chart.
So congrats to one of the best segments. perhaps because we called it "mom's story".
And for those of you who believe that watching her suffer was "trendy", my family have other thoughts-
by wayneb59 November 24, 2009 2:25 PM EST
I would appreciate the viewpoints of other health-care providers on a correlation I see all the time in my work: Education and income seem to be inversely related with the quantity of end-of-life care requested. It's empowering, I think, for people who have so little, and feel so alienated within the health-care system, to be able to direct so many health-care resources toward themselves and their families simply by requesting them. At the opposite end, those (and their families) who better understand what extreme measures cost seem much more accepting (in many cases even demanding) of advice about when to stop.
That's not so say rich people are less demanding of the health-care system. They are just more likely to demand treatment by providers they perceive, based on reputation alone, to be of higher quality, without any regard to outcomes data.
by Murphy849 November 26, 2009 11:10 AM EST
I agree with your observation. One problem is that most healthcare professionals are from a higher income status and we are not good at communicating with those less educated. We use words that are confusing to them and they in turn lack the confidence to ask us for clarification. There is some mistrust, so when three different doctors say three different things, they tend to "hear" the most optimistic version. They never get a clear picture of their loved ones ability or inability to recover fully from their illness. I recall sitting with families while we looked at their loved one's chart together. The physician notes would say "prognosis is grim." The families would be shocked as in all the conversations, they never understood that their loved one was more likely to die than to live. So I believe improved communication is the key in addition to addressing the family member's emotional response and grief. It takes a lot of time and for all the health providers to be saying the same thing to the family repeatedly. The family needs to move through the stages of shock, anger, sadness to be able to make good decisions.
by olyboy November 24, 2009 11:46 AM EST
All good points, but they miss the point. The government, in medicare and soon in all coverage, dictates what the care provider can charge. Under the current system with my insurance, out of system doctors have to be paid out of my pocket if they charge more than the coverage. That gives me the option to seek care from specialists who are the best at what they do. If they are limited in what they can get for their skills, they will take them elsewhere (the UW medical school is already struggling because the brightest students are opting to go into dentistry and other diciplines). Think of the quality of service you get at the post office or DMV. That's what happens when the quality of care has no relationship to the benefits of providing excellence.
by ChangeMe53 November 24, 2009 9:57 AM EST
Thank you CBS for the courage to bring this story into our living rooms. I am a registered nurse, and can assure you that the great majority of doctors do not have end of life discussions with patients and families. They may chart in their progress notes that they have, but conversations with the family and the patients will indicate otherwise. Nurses are left with the heart-breaking responsibility of caring for the patient and family when we know there is no hope, yet the very person and their loved ones who need to know, don't. One of a nurse's most important professional roles is being an advocate for the patient. Compromising that weighs heavily on my heart when I fail the patient at the end of their life by being unable to make this last part of their earthly journey what it should be.... surrounded by your loved ones, physically comfortable and supported emotionally and spiritually. I returned to the "curative" care environment from hospice care, and I can't wait to get back to being a hospice nurse where I knew my work each day brought comfort to my patients. Everyone should take the time to have conversations with their spouses, parents, grandparents, children... LONG BEFORE it's medically necessary about our wishes at the end of our lives. If you know your loved ones wishes, especially if they are in writing, HONOR THEM. It is the most loving, courageous thing you will ever be asked to do, but the grace of a compassionate, comfortable passing is a great gift.
by cleric60 November 24, 2009 8:15 AM EST
As a medical staff chaplain, I encourage call my patients and their family members to talk openly about end of life issues. I encourage them to fill out a POA for their future health care wishes. Sad to say, many elderly patients desire to enter eternity; but their children don't want to let them go for one reason or another.
So the question is: Do we prolong living or suffering and the dying process? One's faith does play an active role in the end of life discussions.
by Sodamary November 23, 2009 11:06 PM EST
Go do some research on how Medicare policy is worded and you'll see that "end of life" discussions have been and always will be a part of the Medicare policy. It's nothing new. I am confused as to why so many people are against government run health care, yet scream bloody murder if Medicare is ever threatened. Medicare IS government run healthcare, and its almost as old as President Obama himself. It was began by President Johnson as part of his Great Society program, along with Medicaid. Both programs sought to reduce poverty and increase access to better healthcare for the elderly and the poor.Having been involved in the legal aspects of insurance for nearly thirty years, I can safely say that "death panels" have been an integral part of large private insurers for many years, only they refer to them as "decisions to deny treatment/coverage" or "treatment parameters" and "exclusions". They are set encoded reasons the insurers have to deny payment for services, or limit what they will pay for. Reasons to deny can range from "experimental" to "not medically necessary", or maybe your just not "in your care network".The real injustice about these decisions are that they are not necessarily made by educated medical personnel like physicians and nurses. They are put forth by employers, underwriters, brokers; in other words by people who are not looking out for the health of the individual, but more concerned with the financial bottom line.While I have grave concerns about what team Obama has in store for us regarding healthcare, I don't believe it could be any worse than what private insureres have successfully managed to get away with for much too long.
by DoctorFisher November 23, 2009 7:40 PM EST
This is never simple. My specialty is hospice/palliative medicine and the best tool I carry in my doctor's bag is "The Conversation". The most tragic line of this story:
'Though she received $40,000 worth of care in her last two months of life, not one of her 25 doctors sat down with Dorothy Glas and her family and discussed how she wanted to die.'
Doctors must learn how to discuss end-of-life with their patients, and patients must demand it from their doctors. An attempt was made to encourage these conversations by adding a Medicare billing code for doctors to use when they sit down with patients to discuss these issues. Unfortunately, this was skewed by some media into the creation of 'death panels'. I am not in favor of government-run health care, but it makes sense to promote good conversations between doctors and patients so we can help patients take control, as much as possible, of the circumstances surrounding their death.
by mcapek November 23, 2009 6:36 PM EST
First of all, our parents HAVE paid TAXES into Medicare all of their life. So the end of life care is not FREE GIFT from the government. And lets face it, its easy to label people as delusional and unable to let go. Reality is that if you are not a medical expert, you would not know all the nuances and statistics about a specific disease and its treatment. Just because a hospitalist thinks the prognosis is "bad", should you pull the plug? Are YOU ready to do it to your father, mother or ill child, or would you rather wait and see what happens?
by RRTMO November 23, 2009 6:20 PM EST
Being a Resp. Therapist for 21 yrs, I am the one called to "pull the plug". It is often the kindest thing that has been done for the patient. Drs. talk to families every day(every hour!) to help families understand the situation. Families often aren't ready to say goodbye so they choose to do everything,even if the pt. has metastatic cancer, alzheimers disease, or are 100 yrs. old etc. Often the families are mad at the Dr. for what he/she said, they "believe in miracles". I have had patients on life support for yrs, on dialysis for yrs, unable to eat or drink, their hands restrained because the pt. himself tries to pull tubes out. The family insists that all this care is given, regardless of quality of life. They also know medicare pays the bill and there is no limits to what is done. I know I don't want aggressive care if I am terminal and my family is well aware of this.
by diamruby November 23, 2009 5:51 PM EST
Most old people do not get to make their own decisions once they get sick, the children also do not want to use any of the parents savings as that will cut into their inheritance. My mother was dirt poor & we took care of her at home until she was so bad we had to put her in a nursing home. The cost & quality of care is horrible. She was filled full of things that could not possible help her at the end of life such as vitamins,& a stupid diet, they charged us for a MRI that she never got. We gave strict orders for her to be kept out of pain, safe & to eat whatever she chose to. She did not want to be kept alive trapped in a body & mind that did not work, every day she was alive she was in terrible pain, she was ashamed that she could not care for her personal needs. The after life is an unknown to everyone but it is a fact that we all die. We should not spend millions of our taxpayer dollars on procedures that keep a person alive but not living. No one in their right mind would want to be kept alive on a machine, filled full of pills,in diapers, force fed & strapped in a bed. Why is everyone afraid of dying? The end of life could be alot better if we are allowed to make decisions based on the truth from our doctor & what we want for ourself. People that prevent their loved ones from leaving are extremely selfish.
by buxton53 November 23, 2009 5:37 PM EST
Wow what a touchy subject, very personal! I think somehow the expensive testing that goes on needs to be controlled however I don't think doctors should be permitted to play god and "pull the plug on grandma," which the doctor on this segment described as a scurrilous comment but pulling the plug on grandma is exactly what he is proposing in an effort to make sure uninsured Americans receive insurance. How a person is treated at the end of their life is a deeply personal decision between themselves and their families. Hospitals shouldn't take advantage or play CYA (how this is done needs to be decided) but the patient and their families should finally decide when it is time. Truthfully patients who have insurance at this stage of their lives, who have worked hard for it all their life should have a say in how they die. Tort reform which I believe is a much bigger hole needing to be mined for savings is not even being discussed. I guess a big payday for lawyers are more sacred then the end of any one person's life!
by mcapek November 23, 2009 5:34 PM EST
It is not as simple as you make it seem. When my father at age 84 suddenly developed bacterial meningitis (despite being vaccinated against pneumococcus), he was given a chance of 80% death, and 20% survival, with infectious disease specialists that deal with these cases saying that if he survives, there is a possibility of good outcome, that some patients come back from coma and have good functional outcome (able to walk, talk and think). Since he was a healthy 84 year old prior to this horrible infection, we wanted to wait and see. He made big progress 3 weeks in ICU, seizures and post infectious changes swelling resolved, white count came to normal, he was extubated, he started to squeeze hand, still very weak and unable to verbally communicate. Then he suddenly developed hypotension and rapidly died in matter of hours, despite agressive treatment with transfusion, vasopressors, etc. So I ask, if your parent has a 70 or 80% chance of death and 20 or 30% of survival due to serious medial illness, will you pull the plug on him/her? Who is to say that a hospitalist or some committee will decide who lives and dies, because of expense? They have no experience with some of these disease, and I would be more inclined to listen to experts who have managed patients with those conditions.
by jt92202 November 23, 2009 5:19 PM EST
Because it's the Health Insurance Companies fault..... or that is what they have been telling us for months. But it's not, it's the fault of many, Heath Inusurance Companies, hospitals, doctors, lawyers, drug companies and so on but the only ones that the Government is blaming is the bad Insurance Companies.
We have to protect our old and ill but we have to do it without allowing these companies and people to bankrupt the US. I don't have an answer but the debate is just begining, and this debate is going to anger a lot of people.
My dad is 77 years old, he's healthy but has had heart surgury back whent he was 45 years old. But his wife has Dementia, she is 68, she has progressed over the past 4 years to a point that she needs full time care and he is the one giving it to her. He has too much money to get Medicaid but if he puts her into a home where she needs to be then at 10K per month for her care and another 3000 to 4000 for him to live each month, he would be dipping into his savings and that will be spent in less than 2 years. She has no medical problems other than Dementia. She could live for 20+ years. My dad worked hard all of his life so he could retire and have enough to live out his life, we don't know when an illness is going to ruin us financially but it can happen to anyone. His lawyer said he has 2 choices, divorce her or put all of his money into a Family Trust in his name only and apply for Medicaid, Medicaid will pay for her and when he passes the government will come after the Family Trust and take all that was paid for her care. I could care less if they do that because it would be the tax payers money at that point, the thing I worry about is what kind of care are they going to charge for. At 10K a month for her to be in a nursing home how can anyone be able to afford that, he did the right things. Long Term Care at 100 a day but that only goes for 2 years what about the other 18+ years she can live. Saved for the future but one illness can wipe that out in a few short years. He worked for the Union so he gets medical insurance on top of Medicare and part B but the is no coverage for nursing home or home care. He could spend all of his money on the nursing home and then end up on welfare the rest of his life, after working 14 to 16 hours a day just so he could raise his family and be able to retire with a nest egg. Going on Welfare would kill him!
I tell this story because it is one that many of us are dealing with with our parents, what do we do? We need to do something because in the long run this kind of story is what will bankrupt us. One thing that is good about my story, there is money that the government can get in the end. In most cases people are already on medicaid and there is no money to go after in the end and that is costing the taxpayers billions! The cost for nursing care is skyrocketting just like healthcare, the only way to get it under control is to cut costs (not lives)!!!
by jjbmd1 November 23, 2009 5:15 PM EST
This was indeed an excellent (and overdue) 60 Minutes segment. It not only points out the futility and expense of the end of life care (ala Americana), it makes (all too brief) mention of the issue of "defensive medicine" - known better as the "cover your a--" style of practice now in vogue thanks to our legal climate and litigious society. The program also came up a bit short on approaching the issue of "physician assisted suicide." We need to get a better perspective on the inevitability of death in this country, accept it, and then assist our loved ones in as painless a way to die as possible, along with the important elements of dignity and the comfort of not being alone. For those who merely saw "letting grandma die" in this program, I say, "Please never complain about the ever rising cost of health care nor the subsequent increase in taxes to support whatever entitlement system might exist to cover these costs." Simply stated, if you want your grandma to live forever, "Shut up and pay."
by RunsWithWolves November 23, 2009 5:07 PM EST
If the family has to pay the cost directly of keeping geriatrics barely alive for months, then you can bet they would be pulling the plug way sooner! Guaranteed! As long as someone else (taxpayer) pays for it, it's trendy to just let grandma receive futile expensive un-neccessary treatment and continue to have no quality of life. America is the only country in the world that devotes such a large portion of GDP to extending life for people who are dying. A terrible priority and waste of money.
by sdubas November 23, 2009 4:57 PM EST
Dr.Byock is right on target, he needs to tell this to the president,congress,the senate,and CEO,s of all medical hospitals.Let's put him in charge of the nations health care. Hospitals should not be paid for unnecessary procedures on dying patients. When dying is obvious some family can't let go,it should not be left up to their emotions.There should be some kind of nationwide guide to decide what would be allowed on elderly a person with two or more dying factors. If family doesn't agree, they should be responsible for any additional medical expenses.
by mcapek November 23, 2009 5:34 PM EST
It is not as simple as you make it seem. When my father at age 84 suddenly developed bacterial meningitis (despite being vaccinated against pneumococcus), he was given a chance of 80% death, and 20% survival, with infectious disease specialists that deal with these cases saying that if he survives, there is a possibility of good outcome, that some patients come back from coma and have good functional outcome (able to walk, talk and think). Since he was a healthy 84 year old prior to this horrible infection, we wanted to wait and see. He made big progress 3 weeks in ICU, seizures and post infectious changes swelling resolved, white count came to normal, he was extubated, he started to squeeze hand, still very weak and unable to verbally communicate. Then he suddenly developed hypotension and rapidly died in matter of hours, despite agressive treatment with transfusion, vasopressors, etc. So I ask, if your parent has a 70 or 80% chance of death and 20 or 30% of survival due to serious medial illness, will you pull the plug on him/her? Who is to say that a hospitalist or some committee will decide who lives and dies, because of expense? They have no experience with some of these disease, and I would be more inclined to listen to experts who have managed patients with those conditions.
by justsane-2009 November 24, 2009 12:30 AM EST
if i can say this without seeming to be cruel mcapek, your story would have been far more effective if your father had survived. you don't say what the cost of your father's care was during those last three weeks. let's say that since he was in the icu, that his care was the $10,000 per day that has been quoted here. that means that medicare spent $210,000 for his three weeks in icu, with only a 20% probability of a good outcome. if you had been personally responsible for that bill, knowing the odds, would you have agreed to the same course of treatment, or would you have asked the doctors to keep your father comfortable, treat his pain, and let nature takes its course? what choice would your father have made if he had been able to make one? 84 years is a good life, and remember, none of us gets out of here alive...
by 12linus November 23, 2009 2:33 PM EST
I am not expert on ICU treatments but I recently took my wife to the emergency room on the recommendation of our on call doctor. Around midnight they said they wanted to do an xray and some tests. If I had been awake (I am 71) I would have quizzed them on those tests. The xray was totally unnecessary since the doc had listened to her lungs and heard nothing. They did a broad array of tests, only two of them important, testing for flu. By the way, they both came back negative but the doc said that is what she had, not H1N1, even though we both had had our flu shots weeks ago. So here we are 14 days later. The chills and high temp are gone but the daily headaches continue. I called her doctor's office and said I want to bring her in tomorrow. I also said I want her to see her doctor not the PA. They said the PA works with the doctor which is usually not the case. I mean they have been trying for months to get her blood pressure and cholesterol under control. Okay, I rely on PAs too, but when something isn't working, where is the doctor? This is ridiculous. You can't see any doctor or dentist, visit any hospital, etc. without signing your rights away, and they still either won't see you themsevles or take hours to do so particularly in hospitals which are understaffed with contract docs at night in our fair city. Okay I've vented. Hope I never end up in an ICU myself.
by itgranny November 23, 2009 1:24 PM EST
that would be a good thing to tackle, but it will never happen. It's too explosive.
I used to work in a home for several years and had to get out i was getting so angry. I didn't mind the work, i didn't mind the people, but the sad part was that the people had better care, better food, better clothes, better housing than i was able to afford for my kid on the poor salary they paid.
There's a young man in a home i know about who's cost of care just went over $2,000,000 on his 30th birthday. That's government money, not his family's. This young man is total care. He doesn't communicate, even with eye movement. He's tube fed. They put him in special built wheel chairs that get replaced every couple of years. They take him out to supper once a month to a trendy steakhouse, pay for the staff to have a steak while he is fed through a stomach tube. he gives no clue to whether or not he even understands that he's somewhere else other than the home. He winds up in the hospital 3-6 times a year with pneumonia.
I wish somehow we could break out the figures of the welfare money it takes to keep these people alive. When they talk of welfare queens, undeserving people on food stamps, free lunches at schools, I see a possibility of making something of these people. But we need to recognize there are some that are just too far gone. This is going to sound callous to some, but I think we need to think of ways to make these people comfortable and let nature take it's course. Our money and resources would be much better spent in prevention.
by MFH17 November 23, 2009 12:44 PM EST
Your response may be from your experience as a hospice doctor, who probably see things quite differently than the patient or even a family members.
I would suggest that you use your ability and experience to fine tune the hospice system so the gaps and holes in it are address so that all going into such a service are allowed the favorite term of hospice, death with dignity.
By my experience the expectation(s) given by hospice and it's production of those services were profoundly lacking. I suggest a look at the qualifications/credentials for hospice nursing is a good place to start.
The family is drawn into to assist with this style of care and left to feel a contributor to any questionable care that arises in reflection in the quality of care that was given.
I would think that the family is usually pretty medically and legally inept and try to do their best in a time of grief to follow the direction of the hospice caregiver who's usually unkown qualification they rely on and continue to do so good/bad so as to not force another change upon their loved one and at the same time respect their wish.
Honest discussion needs honesty.
by jacquelee99 November 23, 2009 10:42 AM EST
This situation is COMPLETELY out of control and I was pleased to see it discussed on last nights show.
There is, however, one important aspect of this mess that you did not discuss; that is the complete lack of assistance available to those families who DO want to bring their terminal loved ones home for end of life care. Medicare will not cover ANY expense in the home.
My mother is terminally ill with brain cancer. She has been shuffled from hospital to nursing facility all under Medicare's directives. For months, I have asked what my options are so that i could bring her home. I was told if I took her out of the facilities the cost to care for her would be COMPLETELY MY RESPONSIBILITY! On top of this, I have talked to dozens of professionals in every area of healthcare and not ONE of them understands how this whole systems works. I could not get an answer to the question..... "How or where do I get help so that I can bring my mom home?" So, instead, she has been shuffled around and has racked up incredible medical bills under Medicare's care. Many of which, as indicated in your story, have been completely unnecessary (i.e. the psychologist that we kicked out of her room).
Can you believe that Medicare will cover the cost of hospital/nursing care (to the tune of $15,000/mo plus) but will not cover the cost of in home help (which would cost a fraction of the hospital/nursing facility cost)? I am a single working mother of two. My mother needs care 12-15 hours a day which I can not adequately provide while working full time. How in the world can I possibly afford to have her at home (which is where she wants to be) and give her the quality of care she needs and deserves? This is insane!
Terminally ill patients in the U.S. have a giant gap in coverage. If you are rich, you can afford private care....if you are exceptionally poor, you qualify for Medicaid(which will pay for in-home care). Those of us caught in the middle are forced to spend our life savings and go deep into debt to bring our loved ones home at end of life...... HOW DOES THIS MAKE SENSE???
Please do an addendum to this story and talk about the gap in coverage between Medicare and Medicaid and the need for some sort of Medicare coverage for those families who want to bring their loved ones home. Why can't there be a provision for this (there seems to be provisions for everything else)? The savings alone would be enormous not to mention the benefit to the patients and families.
ps. My mother has come home with hospice care, however, hospice only covers MINIMAL care until the very end (one hour a day). I have had to hire a private duty nurse to help with my mom's daily needs. The cost is going to use up all of my mom's and my savings and will undoubtedly put me into substantial debt....however, I feel it has been the right thing to do for her.
by Halo3rd November 23, 2009 10:10 AM EST
I began my 34 year nursing career working in various ICUs, and I ended it as a Nurse Practitioner caring for women. My idea of an absolute nightmare is dying in an ICU.
Apparently this was also the view for 85 year old nurse who was seen -- and billed -- by 25 specialists before dying in the ICU. Performing a pap smear on this woman is so utterly appalling as to be laughable ... were it not so deploringly abusive. Abusive in every respect I can think of.
I would like to ask the woman's daughter, "Where were you?". My intent is in no way to place blame, but rather point out other issues in this huge dilemma. Patient advocates/family members tend to relenquish all control when their loved one is admitted into the hospital. They may be afaid of their loved one dying at home ... they may by denying their loved one IS dying ... they are in emotional turmoil ... many people have never even witnessed a death ... whatever the reasons, they allow the hospital system to take over and run its course. Hospitals were developed in order to mend, repair, cure, heal ... and they perform those functions well.
I would hope that were I dying in an ICU, my daughter would do what I have discussed with her. I hope that she would do what I know I would do, were my mother dying in an ICU ... I would disconnect every tube, line, wire, monitor, pump, machine ... I would bundle my mother in blankets ... put her in a wheelchair ... and I would take her home.
by spenb11 November 23, 2009 9:40 AM EST
30 percent 50 billion is just 0.0015 percent of the contribution of these elderly people to US economy on the average. Shame on us.
by Failures November 23, 2009 9:36 AM EST
The most interesting point in this story is the statement: "Individuals and employers ought to be able to spend as much money as they want to have things done." Of course this means the rich, Congress, business execuitves and CBS Correspondents will be receive all the care they want but average Americans will be stuck with poor, rationed care. Another telling statement from the elitists.
by bigmo47 November 23, 2009 6:01 AM EST
No, It's not only in America. You an hae your baby delivered for "free" (taxpayer expense) in most countried with Universal coverage. Yeah Ikn ow this is soxialized mediceine, but they do mange to deliver babies and treat emergencies for Americans travelling in their country.
Some interesting facts about the argument against "socialized" medicine.
1. Will reduce Medicaid and Medicare - So lets not have "socialized" medicine because it will hurt our current "socialized" medical programs.
2. Gives coverage to illegals - Any person that shows up an an American hospitals emergency room must be treated. Emergency care is far more expensive than preventative care and clinic visits to catch an illness before it turns into an emergency situation. Either way, we are paying for it so why not save some money.
3. If Americans want insurance they should have to work and pay for it just like the rest of us do - the "leechers" on American society already receive free medical care (Medicaid), the ones who don't are more than likely homeless and receive their care via emergency rooms. The people that this really hurts are the Americans that work hard everyday, but work at jobs that don't provide insurance and they don't make enough to afford their own policy.
4. It costs too much - congressmen need to look at poll numbers and realize that the majority of Americans are in favor of coverage for every American (not the Fox/Rasmussen polls that ask "Do you favor a government takeover of health care?" - nobody wants a takeover, but most want coverage for every American). IF the republicans will come to grips with the realization that it will happen one way or the other, they may be able to actually incorporate some ideas that may reduce the cost instead, the spend their time coming up with one-liners about Madoff and killing grandma.
We are fighting 2 wars that have cost more in 8 years than it wold cost to implement universal coverage for the next 10 years, we accept those costs as a fact of life. Shouldn't the health costs of Americans be another fact of life that we accept.
by Freedomminute November 23, 2009 4:55 AM EST
I think the most important point in this piece is this statement about why health care costs, especially for end of life care, are spiraling out of control:
"In almost every business, cost-conscious customers and consumers help keep prices down. But not with health care. That's because the customers and consumers who are receiving the care aren't the ones paying the bill."
I basically made the same case in my series on health care reform at http://www.freedomminute.com
Unfortunately, the health care reform plans favored by the President and Congress will only make matters worse since they further insulate consumers from the cost of their medical care decisions by forcing more Americans to buy basic health insurance and covering more of the population under government paid for health care programs. This is exactly the opposite of what we should be doing. Instead of making people more responsible for their decisions, the government is drafting legislation that will make people less responsible for the cost of their health care. As Dr. Fisher so aptly points out, "In medicine we have turned the laws of supply and demand upside down".
by dwyerconst November 23, 2009 2:12 AM EST
Dear CBS,
I just lost my mother on November 12,2009. I can tell you my mother was in alot of pain she had liptheary cancer. Two years ago she was diagonsed with cancer it was around her large intestetine and a kidney, the kidney was removed and alot of her large intestine, we were told by the surgeon that he had gotton all the cancer but treatments would have to be done to make sure it didnt redevelop, and counting the now six doctors she had required, you have a kidney doctor a cancer doctor,a family doctor, the surgeon and the cancer center doctor. My mom had been sick for about a week she went to her family doctor just to be told she had intigiste was given a prescrition told to go home and give the medicine a week to work. Four days of being on the medicine my mom was not better and still in alot of pain I told her she needed to go the ER becauyse obviously the medicine was not working, which she did she was in the hospital for over a week numerous test done cat scan mri you name it they were doing tests finding nothing the pain was in her stomach area. The surgeon who preformed my moms first surgery was her first doctor in charge when I asked him after the last mri didnt show anything if he was going to do something like explortary surgery on my mom to find out what was going he didnt think it was necessary as long as the tests wernt showing anything needless to say after a week of my mom still in terribe pain the surgeon finally agreed to do a scope procedure down my moms throut into the stomach said the procedure would take 45 minutes, 2 hours later the surgeon finally comes to the waiting room where my dad and i had been waiting just to tell us sorry it had took longer than expected but when he tried to do the scope down her throat he could not get into the stomach area he had to open my mom up which she had a incision from right below the chest clear down to about the belly button. The surgeon said the reason she had been in so much pain was there were about 4 or 5 mass around her small intisetine about the size of hes fists. He told my dad he could about gaurentee her cancer was back he would be calling my moms cancer doctor in. I intereppted the surgeon to ask how come after cat scan and the mri she had that neither one of thest expensive test didnt show the masses then he informed me that the mri did show the masses but on the film they didnt look any bigger than hes pinke finger. I feel I lost my mom by this surgeon who thought nothing of doing all of this expensive test at the 80 percent insurance the rest for my mom to pay by not giving her the correct diagonias when he seen the masses on the mri he should of wanted to do the scope immediataly but he didnt he did the expensive test saw what he did but still thinking they were only little masses. Im very upset and I could not put everything else down that was done wrong in my moms case for it has only been a week since I lost my mom I cry often for her I feel if my mom had been the correct digonises from the begining starting with her family doctor to the surgeon my mom would be doing chemo instead of the pain my mom had to suffer so much in the last weeks of her life, that she did.
From A DAUGHTER WHO MISSES HER MOM
by AbdulGB November 23, 2009 1:44 AM EST
A brilliant piece, this was, and punctual, especially in the current climate. Dr. Ira Byock spoke worlds of truth. America is infatuated with youth. This has led to a surgery frenzy and a booming cosmetic industry geared towards 'erasing away the years'. So how do you speak of embracing death if we can hardly embrace aging? Some hope has substance, while others are simply preposterous. Too many of us are not ready to accept our mortality e.g. Terri Schiavo case. It is sad and scary the margin of life one is willing to accept just to avoid death. I think Dr. Jack Kevorkian physician-assistance was in the right direction.
On the other hand, it is appalling what goes on within the hospital. And Dr. Elliott Fisher's inside on hospitals concept of the law supply and demand was no surprise but still awful to hear. Playing business with people's lives is far from ethical. I wonder where do doctors fit in Dr. Fisher's law of supply and demand. How many vacations, luxury cars, condos and homes does it take to keep a doctor satisfied? It is really sad. For Dorothy Glas to undergo some many test, some not even necessary is problematic. But I am glad however this was all aired today on 60 minutes.
by tmittelstaed November 23, 2009 12:53 AM EST
"...As a society, we should pay for people to live as long as possible, IF that is what they want. That is the mark of civilization..."
And yet, in EVERY state in the Union EXCEPT Oregon, husbands who help their terminally ill wives who WANT to committ suicide, will be prosecuted and thrown in jail.
Let me explain how the terminally ill people who choose to end their own life have to die. First, they have to get a pain prescription to morphine or some such. Then they have to deny themselves pain relief for weeks so they can hoard enough pills for a successful suicide. Then the day before they end their own lives, they have to send their husbands, wives, sons, and daughters away, hundreds and hundeds of miles away, to visit someone so that those loved ones can have an airtight alibi. Then on the day they die they have to take their pills, and lie there, alone, for hours until they die. Their loved ones have to stay away for almost a week to make sure that decomposition of the body has set in, before coming back and "discovering" the body. All of this so that the legal system does not ruin the lives of their loved ones by prosecuting them for murder.
by wrico November 23, 2009 12:52 AM EST
I really found this report exasperating because it is so misleading.
Unfortunately, the main drift of the segment is that care should be limited to older patients or patients because they are severely ill.
However, it was clear that the many questionable or unnecessary tests and examinations performed on the patients in the segment were decided by doctors and the hospital. It certainly should have been pointed out by Steve Kroft. The argument that this decision for these tests should just be denied as policy which is unfair, unreasonble and unethical. One sixty five plus year patient can be very different from another sixty five plus year patient.
Dr. Byock's personal view that patients should be denied care because it is not cost effective is the argument by critics who just do not want the government to pay for medical care. Dr. Byock's job is to provide for a peaceful death for his patients no matter how much extraordinary care is provided. When he says that he would not want to receive extraordinary effort to keep him alive is simply dishonest. Studies of intensive care nurses and doctors have shown that no matter what they say beforehand, when the time comes they want to be kept alive as long as possible. This doctor's jobs is not to be considering how much it is costing the government.
This question never comes up when someone is rich. Dr. Byock should and Steve Kroft should be complaining about all the unnecessary charges made by the hospitals. Dr. Byock says that these expenses should not be made when there are 46 million Americans who are uninsured. This is not an either or situation. The 46 million unsured have nothing to do with this example.
Along the same line of thinking is David Walker who is not concerned with the quality of care for patients. Walker's main interest is to keep the government from spending money on social security and medicare. Walker knows that we are not rationing care, care is being denied to Americans and he knows it. It is no accident that Mr. Walker was chosen to comment on this segment since his drift is to limit or deny government services. Both Dr. Byock and Mr. Walker will not suggest positive ways to solve these problems in a way that costs are contained and patients are not denied care. Finally, what conclusion is suggested by this report.
The wasteful expenses of doctors and hospitals should be contained by denying patients care by policy happily enabling Dr. Byock to blame the system and saving money. Really. I hope that Dr. Byock and Mr. Walker do not end with a doctor who thinks the way they do.
by doctorbobb November 23, 2009 12:14 AM EST
thanks to Dr Byock and 60 Minutes for opening the dialog. For all the those who commented who are upset I would suggest to rewatch the video and read the text of the discussion. the hospice movement and palliative care are sophisticated medical interventions that require a large amount of skill and training. not only to provide pain and symptom relief, but to have those hard conversations about what a person values and help them understand what is reasonable and not reasonable to do to protect their dignity.
As a hospice doctor for over 25 years I have had countless experiences and seen suffering that was unnecessary. one case stands out. I was called to help with pain management on a cancer patient on the oncology service. When I walked in it was obvious that the patient was not only in pain but actively dying.
Managing the pain was the easy part. the family had no idea how sick this man was. had no idea he was actively dying and the oncologist was out in the hall talking to a daughter that once he gets better he would do more chemotherapy.
how can a patient and family deal with illnesses if the oncologists just keeps on treating and ignoring the reality of what is happening. the physician was in denial and so was the family. Imagine the devastation to the family when he died.
a balance presentation with an honest talk about what a persons values are and want they want when the therapy is no longer working. pursue one more round of chemotherapy that ends a person in the hospital, or recognition that at some point you will pursue quality not quantity.
one more case that stands out and is exactly the opposite. A man who had throat cancer and was in the hospital for pain out of control. it was difficult to get him comfortable but we did. he had had a lot of therapy and the cancer was progressing. he could not talk because his surgery had been for throat cancer , but he was very alert and one day sitting at the bed side he wrote me a question "am I going to die"
I paused and said "yes", he wrote "thank you for being honest". He became a hospice patient, lived for several months, pursue quality not quantity and died peacefully at home.
Honest discussions help families and patients make better decisions. Look at your life as a book, from infancy to school, to marriage and family and job, good decisions and bad you write many chapters. but we feel death is optional (which for some of you I would point out it is not) so the last chapter is a tragedy and disaster instead of a time to transition on in a dignified and peaceful way.
by LorettaDowns November 22, 2009 11:25 PM EST
The economic expense of prolonging death is small compared to the emotional, spiritual and physical costs we incur treating death like a disease. It is time we accept and support the process of dying the way we have come to regard the process of giving birth.
We prepare for birth in advance. We train midwives and doulas. We offer choices. We teach classes on how to give birth. We share birth with those we love so no one is born alone. We address the physical pain. We design comfortable birthing rooms that feel like home in the institutions where birth occurs. We cherish the experience despite the necessary unpleasantness that comes with it. We do not fear it; we honor it.
It is time we face death with the same openness and support we give to birth. We need to talk about death, the universal, inevitable experience we will all have. We need to prepare throughout life because death does not only come to the old. We need to know why ?Pull the plug!?, ?Just bury me in the backyard!?, and ?My lawyer knows where everything is,? do not constitute useful advance directives.
We need to be teaching the philosophy of hospice care in our schools. We need to require courses in caring for the dying in all the schools that train professionals to care for the sick.
Most of us will not die at home. We need to create comfortable private rooms in the institutions where death occurs, providing sacred space for vigil time where loved ones can gather to hold hands, to say goodbye, to say I love you, to be there.
It is time we leave this life with as much love and support as we come in. When we do, the benefits to everyone will far exceed the costs. We cannot do this if we refuse to recognize that death is a spiritual experience, not a medical event.
by Wanamassa November 22, 2009 11:23 PM EST
Not all palliative care is equal. A "pain free" end is not necessarily as advertised. I've seen it twice. Once with my mother and once with my aunt. The hospice nurse recommended morphine to ease the implied pain. It was the last either were coherent. They died a few days later. I wonder what was going through their minds those last few pain free days as there bodies tried to fight death shaken by the opiate to ease their "pain".
The hospital was no better. A urologist billed my mother 3 times after he told me she would die within the week. A surgeon charged for a cathertization he told us was too risky, which he did not perform. I dared not to notify the insurance company because I was totally exhausted and did not want to be billed by the surgeon if the insurance company failed to pay.
We tried hospice care at home. My mother sat on the couch, I on the chair, when the visiting nurse and helper arrived. We were happy to have help during her last days. The nurse was curt and the helper brusk as they rattled off a long list of those choirs they did not perform. I showed the b itch and the toughy the door and spent the rest of the day comforting my mother.
I rarely got more than 3 hours sleep the 9 months after my mother was diagnosed with liver cancer. My brother and sister visited one or two weeks those 9 months to give me a break. They complained that I stayed in the house and didn't use the time off some other way.
That one sibling that becomes the care giver has to put up with so much of the reality like the ambulance-taxi bills taking a parent for tests, the doctor's visit with undelivered tests, the bill collectors trying to collect payments for services covered by insurance but not submitted by the hospital or doctors office, and the fairy tales about how much malpractice insurance costs caring for the elderly.
Try getting some of that $10,000 a day money to the caregivers. More people would be happy to die at home. Also, go easy on the opiates. I don't believe some know what they are doing or maybe they are just making their jobs easier.
by Jack Meyer--2008 November 22, 2009 10:35 PM EST
I worry about the role of religion in this issue. I think that it is reasonable to come up with a set of guidelines for appropriate treatments for different health situations. This makes sense. A limited extension of life, especially when it result in limited capacity in living, cannot be reasonably supported at the expense of the greater good. This is rational.
But, when crisis occurs, many people often turn to the magic of religion and faith. The belief in a miracle is a powerful elixir, stimulated by the love and legitimate concern of those close to the patient.
I think this is a fair topic for discussion and understanding. But more importantly, given the vitriol with which political extremes "spin" discussion, I worry for a society that embraces the emotionality of belief and dramatic presentation of issues, rather than a society that acts rationally, and humbly, for the greater good.
by jwdryden November 22, 2009 10:35 PM EST
How dishonest; At the tax payers expense??? I'm 61, I've been paying into MediCare for 45 years and I haven't rec'd a dime. Now I should feel bad about taking from the taxpayers?? You do the math. I'm prepaid.
by askagain November 22, 2009 10:27 PM EST
This is something that I witnessed firsthand with my father. He had a stroke and was in the hospital for about a week. At mealtime, someone brought in containers sealed in wrap or with a lid on it. The food just sat there. I would visit see the food, and feed my father. The nurses and aides provided no assistance. The day my father's doctor released him, we discovered that he could not walk. Neither his doctors nor the nurses knew that he couldn't walk. They simply put him in a wheelchair and rolled him to the car. When I questioned his primary doctor, she said she didn't realize that my father couldn't walk. The bill for this horrible service ran into the many thousands of dollars. The bottom line is elderly people are ignored in hospitals. It is nothing but a racket for the hospitals.
by ChristopherThomasMD November 22, 2009 10:27 PM EST
Fact Check 30% waste since I am certain that is complete bull. Dartmouth Atlas can not of possibly reviewed all the medical records to verify that figure as gospel.
Also, doctors must obey the wishes of next-of-kin state laws; therefore, have little negotiating power. As my father passed, specialists did discuss findings with the family and the data was determined to figure out next steps. Hospitals do have in-hospital palliative wards that help in this regard.
60 minutes aim to cast a shadow on a problem when it could focus on the solution. On a nationwide conference call with AMA and the White House, a doctor specifically asked the administration to have a White House sponsored conference on palliative care and death. President Obama and staff owe the public the duty to follow through on this recommendation.
The public will not change their views on death and dying without a national effort and discussion.
by MFH17 November 22, 2009 9:57 PM EST
I find the timing of your "piece" interesting. As you may know a patient can't get anything but a cash price for a prescription without a submittal to their insured. Perhaps a good follow up story for you would be the results of such a choice as hospice. From my experience I would not recommend it to or for anyone. Questionable care is hard to look back on after a loved one has passed. I came to find that the National Hospice and Pallitive Care and the state associations only use complaints as "educational tools". HIPPA also is still in effect even after death except for the most part the heir. For many families that heir is an elderly adult with their own grief, family and medical issues of their own.
I do think it is relevent to speak with the family and patient about choice and hopefully before it becomes a quality of life situation. But who is Dr. Byock that he should talk to anyone in the manner and tone that he did. If that is his thinking put it on paper for when his time comes so his family knows what to do. This thinking that Dr. Byock mentions is in part a transition and also a choice.
From my experience a hard look at hospice should be in order and it's many painful repercussions when it is done shall we say badly.
by melchg07 November 22, 2009 9:55 PM EST
I think the point they were trying to drive home is that people need to start thinking differently when they are getting to the point where they are getting to the end of their days. The doctors should be very informative and be able to let the patients know the consequences.....the costs.....and other pertinent facts (such as time needed for recouping after a operation or the success rates for the operations/tests and how many months it would add to your life)
Tort reform is a decent idea, but to go off on a tangent at 60 Minutes becuase you refuse to acknowledge that there are other things that are needed to be done, other than just simply tort reform.
If people are requesting to do major operations at age 90 which would require months of re-coup time and costs several hundred thousand dollars, but yet were never fully informed that the operation would only likly add a couple of months to the their life, most rational people would decide against it since you have a couple months eaten up by the recoup time.
There is ABSOLUTELY no lawyer involved in that example yet many thousands of dollars could potentially get spent on something that would offer little of real value for the patient despite the high costs involved. Get it now?
by Kuriousone November 22, 2009 9:53 PM EST
Glad to hear your mother is doing well. I work on a rehab unit and would like to make a point or two for consideration. First off, elderly people can, and do, fall due to a host of reasons-their balance is off (unsteady gait), weakness; effects of their precribed medications; medications/alcohol their families give them and don't tell the staff about (yes this happens-alot); confusion due to dementia/alzheimers; refusal to call for help when they want/need to get up, forgetting that they cannot ambulate (walk) unassisted (and yes this does happen-alot), the list is endless. Unfortunately, injuries can occur because of these situations, and/or exacerabate their underlying medical problems.
On to your concerns about the costs. Rehab units, which are often inside of nursing homes are heavily governed by The Department of Health and Human Services-"The State" as they are more commonly referred to. The State mandates the minimum type of care for these patients and how this care will be delivered. This is on top of the facility policies, various discipline policies (doctor, nurse, social worker), etc. Hospitals are also heavily governed by regulatory agencies and various discipline policies as well. EVERY ONE of these entities have policies about how a patient's care will be handled. I am sure that by now you are seeing how costs can sky rocket over a simple thing such as an ear infection. For you or myself, we just go to the doctor, get it looked at, get our presciption and go on about our daily business. A referral to a specialist is nothing more than an additional phone call/trip, etc. Not so with a patient on a rehab unit or in a nursing home. Think about what a "simple" trip to the doctor would cost for someone such as yourself if you had to rely on someone to take you. There's the cost of transportation, someone to go with you, cost of seeing the MD/PA/NP, medicines, follow up appointment, if needed, etc; it's not cheap. If it's an emergency, there's the 911 cost, ER bill, MD/specialist, surgical costs if needed, so forth and so on. Facilities have to rely on ambulance/"ambulette" services for patient transportation for patient safety due to their medical conditions/physical status. They can't just put a patient in "somone's car" and take them to their appointment/hospital.
You are blessed that you had the available time to spend 4-8hours/day with your mother and can now have her at home and provide her with 1:1 care, most people aren't that fortunate due to work, obligations, etc. I wished that ALL of my patients could have a 1:1 cargiver, but reality is what it is.
In closing, I understand your frustrations and concerns. I recently went through this with my mother. She just passed this week after a fall and stiking her head. Nobody's fault. She was a diabetic with blood pressure problems (medical condition/medications), not in the greatest physical shape (not compliant with PT), was supposed to use a walker (unsteady gait/weakness), dementia (would forget that she needed to use a walker) and also stubborn (refused to use it when her faculities were with her). I miss her tons and she will be in my heart always, but I take comfort that she is in a better place and never has to deal with the trappings of an aging body again. I wish you many moments of happines with your mother, she is a very blessed woman.
by chastad November 22, 2009 9:23 PM EST
As a practicing internist and someone who has had both parents die from protracted chronic illness I have a few insights regarding end of life care:
1)despite people understanding the IDEA of dying, the reality is often (whether at home or in the ICU) disorganized, messy and sobering.
2)it often takes time (and money) for patients and family to come to the same realization of what they are witnessing and what the probable outcome will be
3) often there is much of fear, guilt, ignorance (on all sides: doctors, nurses, family and patients)
4)relationships, relationships, relationships! The decision makers (typically the pt, primary care doc and family) need to have had some sort of running dialog over months or years...prior to the difficult, end of life discussions. The ICU doc, specialist or hospitalist who has just met you typically cant develop this rapport in shot order.
by WKReid November 22, 2009 9:16 PM EST
As an oncologist I am faced with end of life battles on a regular basis. The arguments about cost at the end of life have been made for as long as I have been in practice, 28 years. There has been a steady movement away from prolonged end of life battles. The Terri Schiavo and Dr. Kevorkian cases epitomizes both ends of the spectrum. But there is another side that is rarely brought out. The true cost of medical care in America is highly inflated. About 10 years ago the cost of a hospitalization was exaggerated by a factor of 15. That is a $15,000 hospitalization really cost $1,000. And that factor may be even higher now. A review of the website Hospitalvictims.com will show that the profits in hospitals is truly amazing. Between hospitals, health insurance and pharmaceutical companies the profits are so huge. In most towns in this country, the hospitals own everything. Most of the cranes in cities are swinging over a hospital complexes whether or not the economy is rising or falling. Most American hospitals have bank accounts overseas, often more than one.
So before we talk about the high cost of managing dying patients, shouldn't we understand that the medical-business complex has inflated the real cost of doing business.
by LillyJulie November 22, 2009 9:13 PM EST
i was extremely upset when Steve Kroft interviewed the doctors concerning the cost of caring for the the horrors and unthical standards of health care the elderly are receiving. Our neducations are not healing and causing overcrowed hospitals. Anti freeze is in our medications, food, csmetics, health products and causing harmful unecessary harm leading to death. Mr. Kroft when doctors spoke about nedical care for patients---you shoud have reported the corruption that is in health care research---repeated and repeated research that has been done over over again. Trillions and billions of doallars given to universities that are wasted. It is criminal abd misrepresenting the people. PLEASE CHECK OBAMA'S HEALTHCARE STIMULAS RSEARCH THAT IS UNCESSARY AND WASTING THE TAXPAYER'S MONEY. PATIENT SAFETY PROGRAMS WERE ORGANIZED TO PROTECT THE DOCTORS, HEALTHCARE INDUSTRIES AND THE PHARMACEUTICALS---A PATIENT SAFETY IN NAME ONLY---DOCTORS ARE NOT REQUIRED TO REPORT ERRORS---ONLY IF THEY WANT TO VOLUNTEER. CBS ALLOWED THE DOCTORS TO GIVE THEIR OPINON---AND WHO IS DAVID WALKKER TO SAY PATIENT CARE IS BANRUPTING OUR GOVERNMENT---HE WAS DIRECTOR OF GAO AND KNEW THAT ALL AGENCIES WERE NOT ACCOUNTABLE AND COULD NOT ACCOUNT FOR TRILLIONS OF DOLLARS. SHAME ON 60 MINUTES FOR SUCH A CORRUPT PROGRAM! MR. KROFT IT REMINDED OF AN ACCIDENT ABOUT TO HAPPEN---ONLY IT WAS A COMMERCIAL ABOUT TO HAPPEN---CORRUPT AND UNETHICAL. SHANE ON CBS
by mikecbsnews November 22, 2009 9:08 PM EST
It seems as though 60 minutes has adopted the perspective of our president, who has twice accused physicians (on national tv during his incessent and ubiquitous press conferences) of ordering tests and performing procedures for the purposes of making money. This is grotesquely insulting.
Health care costs in the final months of life are astronomical. This is sad, dangerous and requires comprehensive reform. But to insinuate that physicians motive is profit is ignorant. Like the health care reform debate, this issue has little hope of moving forward without discussing TORT reform. It was not mentioned once in the 60 minutes story, as it is not mentioned once in the 2000+ pages of the House of Representatives Health Care Reform Bill. I'll try to keep it simple: costs are too high because doctors order too many tests. Doctors order too many tests because lawyers won't stop chasing ambulances. Lawyers won't stop chasing ambulances because it makes good business sense. Insurance companies are quick to settle and then pass on the costs to physicians in the form of higher premiums. There is no substantial penalty for frivolous litigation...and round and round we go. Congress is over run by lawyers...the president is a lawyer...shame on 60 minutes, they're supposed to be journalists.
by afliberatore November 22, 2009 9:02 PM EST
Ok, let me continue. Since resources are not unlimited and decisions are already being made, might as well give it to the government to handle.
Simply because a medical procedure is available does not in any way automatically give everyone title to it. But the instant the government injects itself into the process, an entire set of new decisions and constraints emerge. Government provision and limited resources means that the government must ration the available supply. And since it is not fair for those who have money to buy what is not available to others, the government will naturally restrict what others might wish to purchase.
This leads to the current state of affairs that if equity is the first and overriding goal, then questions of how medial care is delivered are never asked.
Well here are a few. Why are hospital costs of high? Why should one be willing to simply accept the notion that it costs $10,000 a day to be in an ICU? Or that it costs $1,000 to spend an hour in a recovery room after outpatient surgery.
The excessive intervention in the market by state an local governments has already nearly destroyed the medical care delivery system. Doctors, nurses and health care professionals are a caring and committed group who we all thank. But their ability to diagnose and prescribe medical issues, which rests on their understanding of physical body systems, does not carry over to the economic body.
Hospitals are an inefficient monopoly. Any inquiry into the cost of dying should examine the determinants of cost, not simply accept the fact that it is expensive and that since individuals have limited resources, we as a society should go to the public purse and create a bureaucracy to allocate available resources.
by RNsince86 November 22, 2009 8:52 PM EST
The Sunday talk shows were full of debates over healthcare today. It prompted me to tell my husband that I wish someone would ask nurses what the answers were. A nurse would have the answers on the tip of their tongue.
Without hesitation, a nurse would say to start slowly and deliberately. Nothing related to promoting health responds well to dramatic untested affronts.
Then the nurse would tell you that litigation reform where someone could sue for true injury would change the entire financial picture. Unnecessary tests and people who are not happy with their outcome would need to disappear. Another practical nursing point of view would remind patients that outcomes are not always what they wish, but that does not mean anyone did wrong.
Next, the elimination of the protection insurance companies from anti-trust laws would allow for real competition in the industry. Allowing patients to buy the best packages for themselves and their families across state or other preconceived lines would actually create competition. Unlike the government run program, which will inevitably lower quality of care while skyrocketing costs as it has done with Medicare and the Veterans? Administration.
Being the absolute realist, a nurse would also know that these two items are the least likely to happen as congress is full of lawyers who receive large sums of money for their campaigns from insurance companies.
That leaves the topic of your recent story- end of life care and its cost. This is a subject that a nurse know and cares a great deal about. I watch as people with multiple debilitating illness or terminal ones endure very expensive tests, procedures and hospital rooms because the doctors, patients and their families are afraid. Some are afraid of dying, some of feeling guilt and some of getting sued.
Many people worry about rationing, but none would exist if these groups would deal with the end of life with realism. Truly, there are worse things than dying. Lingering, suffering and pain are just a few examples of what most people wish to avoid at the end of their life. All it takes is true strength and honesty in dealing with the fact that we all die. Death, a nurse would say can be the greatest of compassion and the best of care.
by beareagle1 November 22, 2009 8:42 PM EST
I was sickend by the episode re: end of life hospital care. Not once was the term DRG's mentioned (this basically states that the hospital is paid by the patients admitting diagnosis NOT the tests/ procedures preformed durring an admission.) Hospitals are the only business that I'm aware of that has this type of payment. Hospital acquired infections, bed sores ect are also NOT paid for.
This story seemed to be more about saving money and not about taking care of our elderly people. Scares me to death that a price tag is being placed on life. Also makes me wonder whats in store for me when I'm older.
Why don't we start by evaluating our medicaid system. I'm all for giving assistance when it is needed but we are raising generations of people who don't use medicaid as a tool for tuff times but instead as a way of like. They visit emergency rooms for free (at the taxpayers expence) they have multiple children (at taxpayers expence) they get expensive outpatient tests for free when those with health insurace are at the mercy of their insurace carrier.
by aroye November 22, 2009 8:30 PM EST
I have two comments in response to this story.
First, regarding the comments from the former GAO officer, where he speaks of this being "the only industry where the patient does know or care what the cost is." This comment does not phase Steve, normally a fair interviewer. So I will. After the press pilloried Whole Foods owner's insurance program, I am not surprised. Whole Foods' program shows the incredible difficulty, if not impossibility of finding out the cost of any porcedure beforehand if you are the insured. I have tried. I expected to require valve replacement @ the Celeveland Clinic, and was trying to determine if I could afford it if i remortgaged my home, or sold it. This covered surgery ranges from $135k to over $250k not including ancillary costs. You can imagine my need to determine the cost. I couldn't. The insurance company said they would not know until they received the claim. The group who knows my insurance company's "usual and Customary Charges" to compare to the standard Hospital charges are the only ones who have access, and they determine that after they get the bill. You can see the problem here.
Do NOT blame the consumer or Whole Foods owner who are trying to make intelligent choices but are thwarted at every point by the entities pointing their fingers back at us.
Second, to all those who feel this is a step away from genocide. Currently, the ONLY right the patient has is to sign a DO NOT RESUSCITATE, meaning if the body dies, they will let them die. We, as Americans however, do NOT have the right currently to allow ourselves to die. Once you are in that hospital, they are obligated to leave no stone unturned in case some family member/lawyer decides to sue them for negligence. Think about that one.
Thank you
Ashley
Tulsa, OK
by labelle50 November 22, 2009 8:22 PM EST
My 92 yr old mother entered Glen Cove Hospital, part of the NSLIJ health care system on September 25 for a simple shoulder replacement. The operation was successful and she was due to be discharged two days later . Early in the morning of her discharge date I was notified by a P.A. that she had fallen out of her bed and broken her hip, please come as soon as possible. When I arrived at the hospital 45 minutes later I was met by the attending P.A. with , "we are sorry but accidents happen. Don't worry Medicare will pay for this." My mother underwent her second surgery in 5 days, spent 3 days in the ICU at the insistance of the ICU nurse who was outraged by what had happened to my mother. She was transferred to the recovery unit, the same bed where her accident occurred. Her neighbor in the room spoke to me and strongly felt that i contact hospital administration about my mother. My sister did so and is still waiting to hear from the hospital administration. While in Glen Cove Hospital my mother received 3 blood transfusions and insulin injections. I took my mother out of sub-acute rehab, another name for nursing home on November 12. To date I receive bills from various doctors identified by name and a number for services not covered by Medicare, not to mention the cost of the ambulette service the hospital insisted I use to transport Mom to the sub-acute facility.I saw her hospital appointed physician once and her rehab doctor once. I contacted her social workers to get updates and arrange her release. i am sure she would still be at the rehab center until the 100 days of subsidized Medicare payments ended. I am waiting for the bill from the ENT doctor that came to examine Mom on a Friday evening at rehab because she complained of an earache.If I had not spent 8 hours a day at the hospital and 4-6 hours a day at the rehab/nursing home with my mother I feel she would not be a with me today. Other patients I saw in ICU and Nursing Home were not as fortunate. My mother is doing fine under my care with P.T. being done on an out patient basis at my local hospital, payed for by Medicare. Susan Drost-Plante
by laurtayp November 22, 2009 8:21 PM EST
This story was good. It is so sad to read the comments from people who are trying to make this about politics. Sometimes things are what they are. Dying is what it is. My father only died weeks ago, in the past he had said no heroics, DNR. As the end of life came closer he changed his mind. This was not easy on anyone, his doctors, me (his daughter) and the rest of his family. We had a hospitalist who saw the big picuture and explained to him in detail how awful it would be for him to go forward. Still he fought. All of his doctors reccomended against life saving measures...yet still he fought. I was in total agreement with the Doctors and knew it was a matter of making my father less afraid. I found, through this journey, that often times, it is the family memebers who drag things out...it is really just selfishness on the families part that allows these people to linger. I had promised my father he could die at home, however, I realized given the complications that this could end up being a painful frightening death for him and twice as bad for us, so I elected to send him to a hospice. It was the best experience I could have hoped for, not only for my father, but for me as well. I am forever grateful to the doctors who told me the truth and to the wonderful hospice workers who took the fear away and made him comfortable in the very end. I only experienced Doctors who wanted the best for my father and that meant dying a comfortable dignified death, which is exactly what happened. I believe it is the families that drag this process out...not politics, not a Television show. I am sorry that people read so much into end of life. It can be wonderful, it is always sad, but only for those of us left behind. My thanks go to the wonderful people at the Hospice that helped my father, and me, make this amazing transition. Nothing more, nothing less.
by banana_republican November 22, 2009 8:20 PM EST
60 minutes did their best to sell the idea of dying without a fight but did not take issue with all the unnecessary hospitalizations that result from doctorss fear of being sued - even though one of medical community representatives acknowledged that this was a major cause (of unnecessary hospitalizations)
Why does CBS gloss over that issue? (Answer) Because they're carrying water for the Democrats who support death panels but who won't jeapordize their contributions from trial lawyers by pushing for tort reform. Money spent trying to save the 71 yr old woman at the beginning of the segment - BAD. Money spent to protect the lawyers golden goose - GOOD.
by Giveusbackourcountry November 22, 2009 8:19 PM EST
The underlying stance taken by Steve Kroft and CBS sickens me. It clearly is supportive of the current public options and rationing of care our government wants for us. Healthcare is broken and needs to be fixed, but some bureaucrat in Washington has absolutely NO place in making health care decisions for me or anyone else.
There clearly must be changes to manage the increasing cost of healthcare in the US, but supporting a government takeover is the worst possible decision this country could ever make. Tackle this through tort reform, cleaning up the fraud in the government managed programs, national competition of insurance companies, allowing individuals choice and understanding and some responsibilities for their healthcare decisions and subsequent costs.
These steps would lower costs immediately, leaving us a free market, competitive system that would encourage doctors and hospitals to earn customers/patients in the greatest system in the hisotry of the world.
Government intervention will undoubtedly cost all of us more money for which we will receive fewer medical options and less effective care.
Government control and regulation in healthcare today is the most significant problem with the current system. Let competition truly flourish, stop the stupid and frivolous settlement's and lawsuits and cut the fraud out of medicaid and medicare. If the government can't manage fraud today, how will they do it when healthcare is all theirs and 20% of the US economy.
Taxes imposed to finance Medicare
Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount of wages, etc., on which the Medicare tax could be imposed each year.[6] Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the entire 2.9% tax of self employed net earnings must be paid by the self-employed individual, however half of the tax can be deducted from the income calculated for income tax purposes.[citation needed]
[edit] Eligibility
In general, individuals are eligible for Medicare if:
* They are 65 years or older and U.S. citizens or have been permanent legal residents for 5 continuous years, and they or their spouse has paid Medicare taxes for at least 10 years.
or
* They are under 65, disabled, and have been receiving either Social Security benefits or the Railroad Retirement Board disability benefits for at least 24 months from date of entitlement (first disability payment).
or
* They get continuing dialysis for end stage renal disease or need a kidney transplant.
or
* They are eligible for Social Security Disability Insurance and have amyotrophic lateral sclerosis (known as ALS or Lou Gehrig's disease).
The 24 month exclusion means that people who become disabled must wait 2 years before receiving government medical insurance, unless they have one of the listed diseases or they are eligible for Medicaid.
Many beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), and also pay for any drugs that are not covered by Part D.
In 2007, Medicare provided health care coverage for 43 million Americans, making it the largest single health care payer in the nation.[7] Enrollment is expected to reach 77 million by 2031, when the baby boom generation is fully enrolled.[8]
[edit] Benefits
The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity.
by margies1953 November 22, 2009 8:17 PM EST
1. As usual, when discussing the ramifications of end of life treatment, the medical team member who is best equipped to assist patients and their families make these tough decisions was completely ignored. Most hospitals have chaplains. A properly trained chaplain has the skills and the resources to spend quality time with care recipients and help them work through their wishes. The medical information a doctor provides is essential, but often overwhelming. Once that information has been relayed, the chaplain can step in to counsel the patient and family and help them reach sensible care decisions that honor both their faith traditions (or lack of them) and their emotional as well as physical needs. Confronted with the information that a loved one is dying, families need time to absorb the facts. Patients need time as well, to process, think, and work out what it is they want. Using someone who is extensively trained in end of life issues and then--very important--honoring the decisions made--could be invaluable.
2. And then there is the issue of family denial. Often families simply cannot accept an impending loss. While Elizabeth Kubler-Ross's stages of grief were never meant to be regarded as sequential, most people do begin with denial. Denial can be a very powerful motivator, causing family members to insist on a level of care that can only be called ludicrous. Since the medical community has a real fear of lawsuits, patients' wishes get disregarded. I have watched many "codes" and extensive life saving measures conducted in spite of the patient's desire to be allowed to die naturally. The reason--family members who do not agree with the loved one's decision. Medical staff is very aware the the dying patient will not sue for disregarding their advanced directive/living will/whatever. The family, however, will still be there and will be a potential plaintiff. So what if they eventually successfully defend against the suit? The costs of defending, including insurance increases as a result of the possible lawsuit, are so high that it is simply safer and easier to disregard the wishes of the patient and do what the family wants.
I have worked as a chaplain for many years. I have seen good deaths and horrible deaths. I'm sure many people will hear only that end of life care is expensive, that someone has got to decide, etc. and the cry of "Death Panels" will rise again. We need to realize that there are things much worse than dying. A graceful good death is a gentle passage into mysteries we humans do not understand. Perhaps we should replace the word death with "reverse birth" or some other silly term that has fewer negative connotations.
I don't normally watch 60 Minutes, but caught it by mistake - and a mistake it surely was. To pick on "the cost of dying" is just as ridiculous (re medicare - which most folks over 65 MAY have paid into for years when they worked and are paying a premium now) as the "cost of living" (ie medicaid - where often the recipient has not paid into any system and delivers a baby weighing in at 1lb, 6 oz and put on million dollar a day machines for up to 4 to 6 months! No one is saying it is "okay" to toss these babies away - which without all of this equipment, these babies would have simply died 40 years ago. I think the whole discussion is obscene - "we all have to die - get over it"...I believe most of us know that! To begin to believe that rationing of care for - what will the age be, what will the condition be - the elderly is not going to happen, then think again. We are slowly getting there! I have worked all of my life since college and if I want to be on a respirator at 88, then by damn, I earned it!! Except by that time, where will the workers be who are being taxed through the wazoo to pay for it!! By the way, in my case, I do NOT want to be on a respirator for any reason and have taken care of such a medical situation! We send folks to prison for participating in a "mutually consenual suicide", but are going to let some governmental body make that decision for us?? Wake up people!!
by origsublime November 22, 2009 8:15 PM EST
We used hospice for a family member who was rapidly failing from cancer. It was clear the treatment was not working and she was very near death. Hospice was wonderful, but since we all work we had to hire a private nurse to actually be present all day with her. Hospice would check on her, give her medication and instruct the caregivers. We would take over in the evening. I hope every town has a hospice chapter. And they can use your donations.!
As for transplants for people 68, people age 68 are really not so old anymore. If they have mechanical breakdowns of heart for instance, once fixed they can have many more years of life with their families and friends. In our family we have 70-year-olds who are helpful to their children by caring for young grandchildren.
We want no government involvement in any of these life or death decisions. That's is not the American way. There are solutions that do not involve government mandates.
There are serious problems with both the Canadian and British healthcare systems. But we aren't British or Canadian. We are independent people, as a rule. To take over our healthcare would be the first step in making us into a weak Nanny State.
by kkirkland2 November 22, 2009 8:13 PM EST
Being a practicing physician for over 40 years, I wholeheartedly agree with the conclusions of Dr. Byock. We will all eventially dye.
Everything in life is rationed. To spend indiscrimently on caring for the terminal ill during the last six weeks of life (some estimates put that figure at over 75% of the medicare budget) is extremely wasteful, especially when we are unable to provide basic care to all. Patient's with terminal disease cared for in the ICU uncommonly make it out of the hospital and rarely regain life with quality. Both patient and family experience prolonged suffering. By being overzealous in end of life care, we, as physicians and loved ones, are interfering with the natural process of dying.
by JimWrangle November 22, 2009 8:13 PM EST
these people were promised a certain level of care. if they are US citizens they have paid for this care. Now, when the rubber meets the road, you just give them some counseling. Can I choose that now, before you idiots steal my money for the next 35 years?
by mdwhocares2 November 22, 2009 8:12 PM EST
It's quite easy to sit back and condemn a family for "having false hope" or for refusing to give up on the possibility of a family member's recovery from a serious injury or illness. The physician on this program seemed to me to be almost eager to talk his patients and their families into DNR status. However, once that decision is made, and resuscitative efforts are withdrawn or withheld, that decision is permanent. Once the patient is dead, they are not coming back. You can always decide at a later time, with more information and after giving time for the course of the disease to progress, to withdraw support.
Also, this argument that most of the health care dollars we spend are around the time of a patient's death is inane. OF COURSE we spend more money around the time of our death. That's because we ARE SICK. Throughout the rest of our lives, we are usually doing pretty well and have no need to spend health care dollars, especially on expensive, potentially live-saving therapies. Using this inane reasoning, then 60 minutes would be astonished to discover that more health care dollars are spent on patients immediately after severe trauma in automobile crashes than on those who are in fender-benders. Amazing! The unfortunate reality is that sometimes people are not yet ready to give up hope and say goodbye to a loved one, no matter what their health care provider tells them, and noone else has the right to make that decision for them.
by SPK22 November 22, 2009 8:11 PM EST
I really liked the smug guy speaking to rationing of care based on the fact that it would be taxpayer funded. I wonder what he thinks about members of Congress who have had their taxes re-done 3 times because they "forgot" about all those assets they "forgot" to claim.
I didn't hear about prosecution and confiscation of that person or their assets.
I wonder if 60 Minutes would have the courage to get some members of Congress on their show and ask, and not let go, that if the health care reform bill is so damn good, then why did an amendment to mandate that the same members voting on it be party to its outcome get removed/defeated. It would truly show whether or not you are journalists or suck ups.
I think many a poll has that answer already.
by origsublime November 22, 2009 8:05 PM EST
There really wasn't much given on the otherside of the dying segment. One of the problems today with caring for people at home is that most people work. Another problem is the type of care seriously ill people need just to be comfortable. How, for instance, is a 135 pound woman going to help a larger relative in personal ways that require two people or the strength of two. How can families with small children and jobs and responsible of a home add to that the care of an elder.
60 Minutes is obviously biased in favor of this; and it sounds so reasonable, but I couldn't help wondering how the reporter and the doctor would feel if it were THEY who were in this state. We've seen a family member rally several times from what appeared to be death's door only to find it was the effects of some new medication or other.
This is a bad idea and it certainly is a bad idea to have GOVERNMENT rules determining what happens at this time. Since you are obviously doing to boost the Democrats healthcare proposal we have to assume you are supporting the idea of the government mandating these things.
And while this doctor says other countries do make such decisions; yes they do. And much of the population now finds themselves in the state of a 68 year old when they must wait 12 to 16 weeks to get treatment for what might be a serious condition if allowed to linger!
That's unacceptable. We are not Europeans; and I find by reading their press that they are beginning to wonder why we love our system so much. It has caused the NHS of Britain to become more vigorous in their promises of improvement.
Unacceptable.
by True__Blue November 22, 2009 7:55 PM EST
Only 60 Minutes would come up with the latest story of pushing on the legacy of Dr. Kevorkian.
Government is NOT the answer to anything...
Instead of doing a story about how to get government out of the medical field and how charitable organizations could be a viable solution they choose to do a story promoting the cult of death...
Many people forget that the works of mercy stem from different churches. Why are so many hospitals named after churches? Historically the church (NOT the government) promoted works of mercy (medicine/healing & caring for the ill) and education.
The solution is never legislation but reform & if not reform, revolution. Sooner or later people will become fed up with having the fruits of their labor stolen by a government who thinks they know how to spend their money better than they do and will fight for the right of property ownership and revolt against the idea of being a slave to the government by having what they work for to own taken by taxes...
Wake up people... Turn from following the cult of death!
From Big Tent Revival
A choice is set before you now
living or dying, blessing or cursing
You know, the time has come around
to turn from your fighting
and rest in his mercy
chorus
Choose life, that you might live
the life that He gives
He gives you forever
Choose life, the way that it's true
from the one who chose you
your father in Heaven
Choose life
Trust the Lord with all your heart
all of your soul and all of your being
Hold on, listen and obey
surrender your life into His keeping
chorus
And the weight you're under
will be lifted away
And the world will wonder
what happened here today
then you'll stand right here and say
http://www.youtube.com/watch?v=LnN33ozmmIc
by sandipn November 22, 2009 8:03 AM EST
One of the very first assumptions, in my view, is very wrong and that is 75% of patients wish to die at home. The research behind this statistic is fraught with problems because most of the research is provider structured questionnaires. If you simply ask the public and many patients the question if they wish to die at home, the answer is yes. That is until the actual time presents itself and the reality is quite different from the assumption. How many times is it said that patients and families do not enter palliative-hospice care (the one word comprehensive philosophy) until it is too late? One of the reasons, not appreciated, is that we have not understood what it really means to die at home. For some it works but for many situations, cancer, place families in the positions of being doctors and nurses and psychologists all at the same time....not to mention trying to keep their daily lives somewhat on track. I just have seen too many families destroyed by trying to have their family members die at home. In part, it is often a displacement of care on to families for cost savings and at what expense? We see great family comments on how good it was that their family member could die at home. More attention is required to elicit actual details of why patients did not wish to or could not die at home.
by November 21, 2009 11:35 AM EST
Cancer care is the largest segment of what is laughably called "healthcare" in America. Medicine has organized itself into a monopoly. Until we dismantle this monopoly we are doomed. Increasingly, we see our friends and family members dying of cancer after devastating treatments feared more than the disease itself. Why? Because we don't know what works. We do not evaluate treatments for safety, efficacy and cost effectiveness. We are losing the war on cancer. More people are diagnosed and more people are dying. As a nation we can not afford to overlook any alternatives for any reason.
Hide All Comments
Posts
No comments:
Post a Comment