More care isn't always better care

"Out beyond ideas...
there is a field. i'll meet you there.
When the soul lies down in that grass,
the world is too full to talk about."

rumi

This morning, I saw the following related comment (from John Dunn, MD, JD) at http://www.heartland.org/healthpolicy-news.org/article/28124/Obamacare_and_Medicaid.html

"Taxpayers will now be forced to bear significant custodial care costs under Medicaid for the disabled. The nation will have to decide how we will define terminal illness, given the unavoidability of mortality and the rising costs of care. Will the advance directive projects described in Obamacare become more prevalent and aggressive? If a person is on Medicaid for custodial care—and 60 percent of the nation’s current nursing home patients are on Medicaid—will a quality of life score determine availability of care and access to resources for the weak and the politically silent?

"Zeke Emanuel, the physician brother of White House Chief of Staff Rahm Emanuel and an influential advisor in this administration, has publicly advocated requiring reductions of care for those with an allegedly decreased quality of life. Dr. Donald Berwick, the Ivy League aficionado of the British National Health Service recently named as chief administrator of CMS via recess appointment, has repeatedly voiced support for stringent rationing of end-of-life care.

"All the evidence suggests Berwick and Emanuel agree with collectivist ethic that calls for reductions in care for the elderly and the disabled and view it as a positive social good. Essentially, Berwick and Emanuel are setting themselves up as the arbiters of others’ health care decisions, casting off centuries of moral and ethical views in favor of a new collectivist/socialist ideal.

This actually gets at something I try and tell my medical research friends: for end-of-life studies, there are three appropriate controls. First is comparison to placebo in the hospital. Second is comparison to the current gold standard treatment. *Third is hospice care.*

It's just remarkable to me how ineffective a lot of modern medicine is at the end of life. Even more remarkable is how we refuse to accept this as the current (though perhaps not future!) state of affairs. Even yet more astoundingly remarkable is how blissfully unaware physicians are of this.

Actually, people who go into hospice care in their last few months of life have a longer expected future lifetime than those who get aggressively treated.

One thing that worries me is that I have the impression that because hospice care is relatively new it attracts providers who are above average in caring and idealism. I can conceive that it could morph into horrible warehouse conditions if the quality of the staff deteriorates and if regular doctors start to dump their dying patients on them. That said, Gawande has done it again and written a powerful article (caring and idealism are a form of social capital).

"It's just remarkable to me how ineffective a lot of modern medicine is at the end of life. Even more remarkable is how we refuse to accept this as the current (though perhaps not future!) state of affairs. Even yet more astoundingly remarkable is how blissfully unaware physicians are of this."

WTF? This doesnt make any sense. Its like saying "its remarkable how little time is left when its minute 89 of a 90 minute soccer match"

If a 90 year old is judged a priori to be "at the end of their life" then it follows by simple deduction that modern medicine wont help them.

At any rate, I dont think you know jack about what most doctors know about "end of life" issues.

I think the point is that modern aggressive treatment isn't going to help a 90 year old with pancreatic cancer a whole lot. When your time is up, it's up.