| Sun Aug. 1, 2010 1:26 PM PDT
In the New Yorker this week, Atul Gawande writes about how badly we manage end-of-life medical treatment. Toward the end of his piece he mentions a study Aetna did with hospice care. In one study, Aetna allowed people to sign up for home hospice services without giving up any of their other treatments. Result: lots of people signed up for hospice care and ended up consuming less traditional care. In the second study, more traditional rules applied: if you signed up for home hospice care you had to give up on traditional curative treatments. Result: pretty much the same.
What was going on here? The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough — just talking.I guess maybe I'm just weird, but this explanation doesn't seem to strain credibility in the least. It's exactly what I'd expect. Obviously there are lots of different people in the world and they have lots of different dispositions, but I'd guess that there's a huge chunk of them who are basically just scared when the end comes and mostly want to understand what's happening. Having someone take the time to explain — to really explain, so that they really understand — probably goes a hell of a long way toward making them feel better. And once they understand that what they're feeling is, under the circumstances, fairly normal, a trip to the ICU doesn't really look so inviting anymore. What's so hard to believe about that?
The explanation strains credibility, but evidence for it has grown in recent years.
What you didn't mention about that piece is that the HCR bill originally provided funding for doctors to sit down and talk to patients about end of life issues, and that's what was characterized by the GOP as "death panels." That item was then stripped from the bill.
So a humane, common-sense-based, and money-saving measure was found to be politically unacceptable.
Agree entirely
So a humane, common-sense-based, and money-saving measure was found to be politically unacceptable.
Agree entirely
Submitted by bleh (not verified) on Sun Aug. 1, 2010 3:50 PM PDT.
And look at the contemporary piece in the Times about the Veterans Affairs suicide hotline. As one of the staffers said, contact matters, even at the end of life.
Americans do not discuss death; they deny it. And when the time comes, they have no sophistication in the subject, so they go for the simplistic. In our case, it is the technological -- throw devices, drugs, and procedures at it. The social/psychological aspect is entirely overlooked.
It's doubly sad that this is becoming noticed only because now, after all this time, it's more profitable to think about LIMITING expensive interventions at end of life than SELLING them.
Americans do not discuss death; they deny it. And when the time comes, they have no sophistication in the subject, so they go for the simplistic. In our case, it is the technological -- throw devices, drugs, and procedures at it. The social/psychological aspect is entirely overlooked.
It's doubly sad that this is becoming noticed only because now, after all this time, it's more profitable to think about LIMITING expensive interventions at end of life than SELLING them.
"a good death"
Submitted by elisabeth on Sun Aug. 1, 2010 4:06 PM PDT.
Throughout out US history, there has been a desire for a "good death." In the 18th and 19th centuries, the focus was on a peaceful death that would indicate that one was in a state of grace, as if the "godly" would have fewer pains than a sinner. And, of course, there should also be a deathbed testimony of one's belief. A few atheists managed to provide their own model of a good death -- including a testimony that they had not had a deathbed conversion!
Now, a hospice-mediated death has become for many a similar goal. Partly because there is a widespread belief that there will be enough pain medications available and partly, I think, because it seems to promise a scene similar to those happy deaths in victorian novels, lots of loving family members around the bed and all tension and strife forgiven and forgotten.
Well, I too, hope for an "easy" death -- but I wonder what percentage of people actually get the option of planning ahead, even to the extent of choosing hospice. Certainly, death often comes as a surprise, or corrollary to some sequence of medical events that cascade until there you are, in the situation you didn't want or expect.
Now, a hospice-mediated death has become for many a similar goal. Partly because there is a widespread belief that there will be enough pain medications available and partly, I think, because it seems to promise a scene similar to those happy deaths in victorian novels, lots of loving family members around the bed and all tension and strife forgiven and forgotten.
Well, I too, hope for an "easy" death -- but I wonder what percentage of people actually get the option of planning ahead, even to the extent of choosing hospice. Certainly, death often comes as a surprise, or corrollary to some sequence of medical events that cascade until there you are, in the situation you didn't want or expect.
"Having someone take the time
Submitted by MaynardHandley on Sun Aug. 1, 2010 5:12 PM PDT.
"Having someone take the time to explain — to really explain, so that they really understand "
"What you didn't mention about that piece is that the HCR bill originally provided funding for doctors to sit down and talk to patients about end of life issues"
There is a second efficiency point here. My suspicion is that the people Aetna has talking to patients are not doctors. I have no problem with this. Personally I want my doctors selected on the basis of intelligence, not personality --- Dr House for me rather than Marcus Welby.
But I think it's an important point because one part of the myriad insanity that is the US health system is the idea that doctors should not just know something about the human body, they should also be a patient's best friend and psychiatrist/councillor/life advisor. This is silly --- there's no reason to have doctors repeating the same speech about hospices (or many other such canned speeches) when reasonably trained non-doctors can do the job just as well, in fact better if they are specifically chosen for empathy and people skills.
I don't know EXACTLY what that part of the health care bill said, but if it required doctors to perform this role, rather than allowing for a broader range of personnel, well that's just stupid --- and it's the kind of stupidity that our system is riddled with.
"What you didn't mention about that piece is that the HCR bill originally provided funding for doctors to sit down and talk to patients about end of life issues"
There is a second efficiency point here. My suspicion is that the people Aetna has talking to patients are not doctors. I have no problem with this. Personally I want my doctors selected on the basis of intelligence, not personality --- Dr House for me rather than Marcus Welby.
But I think it's an important point because one part of the myriad insanity that is the US health system is the idea that doctors should not just know something about the human body, they should also be a patient's best friend and psychiatrist/councillor/life advisor. This is silly --- there's no reason to have doctors repeating the same speech about hospices (or many other such canned speeches) when reasonably trained non-doctors can do the job just as well, in fact better if they are specifically chosen for empathy and people skills.
I don't know EXACTLY what that part of the health care bill said, but if it required doctors to perform this role, rather than allowing for a broader range of personnel, well that's just stupid --- and it's the kind of stupidity that our system is riddled with.
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What you didn't mention about