“Get out of the lifeboat you expensive terminal cancer patients! Sure, your lives could be extended months, maybe even years,–but it isn’t worth the money! You’re going to die sooner or later, so it might as well be sooner. We need the money for more important and productive patients.”
That, in a harshly stated nutshell, is the recommendation of a committee of doctors in Lancet Oncology who recommend money by rationing therapies that don’t save the lives of cancer patients, but can extend their lives. From the Daily Mail story:
Patients with terminal cancer should not be given life-extending drugs, doctors said yesterday. The treatments give false hope and are too costly for the public purse, they warned. The group of 37 cancer experts, including British specialist Karol Sikora, claimed a ‘culture of excess’ had led doctors to ‘overtreat, overdiagnose and overpromise’…’We clearly would want to spare the patient the toxicity and false hope associated with such treatment, as well as the expense,’ the experts told the European multidisciplinary cancer congress in Stockholm.The doctors point out that many patients do not want to spend their final days undergoing exhausting chemotherapy in hospital and would rather be at home surrounded by loved ones.
Oh, quit pretending that it’s for the patient. It’s about money.
Indeed, we are now seeing a drive to extend the cancer of Futile Care Theory beyond ICU-style life-sustaining treatment, to other forms of care in which the patient may not even be hospitalized. When I was researching Culture of Death, I interviewed an advocate of medical futility and noted that refusing ICU treatment wouldn’t save a lot of money. I asked, what will futilitarians try to cut next? He responded, “marginally beneficial care.” And here we are.
Don’t get me wrong. I support people deciding not to go for the last shot of chemo, with the terrible side effects that can bring. But the decision should not be up to the doctors to withhold what is, after all, efficacious treatment that extends life. Doctors should give clear and honest pros and cons of the treatment–including onerous physical effects–but it should be up to the patient to decide whether the time has come to enter a hospice situation.
Patient advocates are pushing back:
But a spokesman for the Rarer Cancers Foundation said: ‘Describing all treatments near the end of life as futile is tantamount to writing patients off. ‘Just because they cannot be “cured” does not mean that we cannot give them valuable treatment, care and support.’ Ian Beaumont of Bowel Cancer UK said money was not the sole issue. ‘While cancer care can be expensive, it is unjust to put a cost on the lives of patients, especially when modern treatments can often give them precious time with their loved ones and increase their length and quality of life,’ he added. Only last week a pill for prostate cancer, Abiraterone, was made available in the UK for the first time at a cost of £35,000 a patient. Although on average it only extends lives by a few weeks, some patients survive for five years.
We all have our stories. When my dad was dying of colon cancer–for which he generally received awful care (I now know) from the Veterans’ Administration–doctors very reluctantly offered him a last ditch chemo that might give him a few months, with terrible side effects. He took it, and the cancer actually went into remission for a year. Not only that, the side effects were few. Indeed, it was a time of relative health for my dad, in which he and mom traveled and he thoroughly enjoyed every minute.
Bottom line: By accepting the philosophical premises of Futile Care Theory, bioethicists have opened the door to now imposing greater restrictions in the name of “fairness.” We should not let utilitarian central planners to take away hope and create a putative “duty to die.”
September 27th, 2011 | 10:29 am
Unfettered access to all the greatest medicine is great. The emotions of most people will love it.
How shall we pay for it?
Equally important, should ALL law-abiding citizens or people – regardless of income – have access to it?
What if it reaches levels that are 25% of the US GDP, up from current levels of 16.2%?
The real debate should be about how much we are willing to spend on healthcare – because everything is rationed. Once we decide that, we can decide how to distribute this service and technology.
We should not focus on scare tactic approaches to framing this debate. It truly is about the money. We need to get serious about it.
*physicians are generally rewarded for volume of care – not outcome. Who cares if one’s sibling had a good, or bad, outcome? Administering chemo (depending on type) brings in less $$ than endless, pointless procedures. This may be the biggest thing we need to change in our health care.
Chris Reply:
September 27th, 2011 at 3:48 pm
@David, Who died and elected you to make a binding law on how much “WE” should spend on health care? Your premise is everything that is wrong and will be wrong with health care in the coming years.
AuthenticBioethics Reply:
September 28th, 2011 at 10:08 am
@David, The question is not whether “everyone” should get it, but who makes the decision. A blanket bureaucratic policy is generally not the best way of making these decisions.
September 27th, 2011 | 3:08 pm
ALL medical care is ‘futile’, life is a terminal conditional without a cure. No one gets out alive. It is such a ‘we are gods’ additude to classify any life extending, life sustaining, or bettering care as futile.
At the same time, health, and by extention health care, is NOT a human right. It’s utterly absurd to consider it such. Most of the medical care we have today wasn’t even dreamed of a hundred years ago. Human rights are fundamental, they don’t suddenly appear. Humans do have a right to pursue or attempt to obtain health and health care. Which means some people will obtain more or less than others. Humans have a right to atte
Jespren Reply:
September 27th, 2011 at 3:13 pm
Have a right to obtain only that which they *can* obtain legally. If a cancer patient care obtain a $1,000,000 treatment there is no reason he shouldn’t be allowed to have it just because his neighbor can only obtain a $10 treatment. Likewise the general populous should not be forced to pay for the $1,000,000 treatment just because it exists and ‘someone’ can afford it. The government does NOT belong meddling in health or healthcare.
September 27th, 2011 | 3:45 pm
Yes! The “duty to die” has become a reality in US Hospitals where the hospitalists are trained to explain to elderly patients the futility of any further treatment in order to get “oral” permission to put DNR/DNI code status in the hospital charts.
In fairness to the hospitalists who are generally very young people, they truly believe that the “quality of life” of the elderly patient is not worth saving and so they gather these “influenced” and “oral” DNR/DNI permissions from the vulnerable elderly within the hospital rooms with no remorse or guilt.
When the hospitalists do it, it does take the pressure off of the “specialists” who are treating the elderly for cancer, etc.. and especially if it is the treatment that has necessitated the inpatient treatment.
But! Wesley Smith is right, this is all primarily driven by “money” and the Right to Die laws that have premeditated big holes in them in order to permit unilateral and secret “cropping” of the elderly.
If hospitalists are influencing DNR/DNIs within the hospital setting, it is probably because they know that so often the hospital is not reimbursed for any time the elderly patient spends in ICU —and especially if the elderly patient dies in the ICU setting.
I am in complete agreement with Wesley Smith who knows through personal experience with his own Father that it is instinctive within the human being to fight to live “as long as possible.”
I am a very old person and I am brought to this subject matter by a personal experience and loss.
I have filed a civil rights complaint because I believe both the hospital and the physician cooperated to deny my husband and me the right under the law to make an INFORMED decision about a life-extending procedure. I believe they did this, not out of malice, but because the hospital would not be reimbursed for ICU time if my husband wanted the life-extending procedure.
September 27th, 2011 | 9:23 pm
I experienced what Carol wrote about. Last year my mother lay dying in a Pittsburgh hospital. When we were questioned about “how far” we wanted to go with her care, the only thing we requested was that if she went into cardiac arrest, that we did not want her resuscitated because of how violent CPR is and she was very frail. When we visited the next day, her fluids and other life supporting drugs had been removed. When I questioned why, I was told that I issued a “DNR” and my mom was now a “class 2 DNR,” meaning all life supporting treatment had been removed except her intubation.
You all can imagine our reaction at this news. I informed the nurse on duty that we clearly said “do not CPR,” and that no one indicated to us that in their system that automated a “DNR” with removal of fluids and drugs. I was LIVID. Her fluids, blood pressure and pain killers were reinstated, but not before that nurse, who I dubbed “nurse death” did her very best to try to convince me to leave my Mom as she was, since her “quality of life” were she to pull through would be “terrible.”
I requested that nurse be removed from my Mom’s care. My Mom died 18 days after being admitted, and the entire 18 days was a nightmare I would not wish on anyone. Yes, we have excellent care and I am thankful for it. However, I learned a very big lesson last year, and that is to NOT sign any paper which would take out of my family’s hands the power over life/death decisions and hand them over to someone who has orders to watch the hospital’s coffers.
I also learned, that “quality of life” is a nice ideal, until *you’re* the one facing a month left to live, a week, a day. So until all those who feel justified in judging someone else’s “quality of life” are in those short-term shoes, they have absolutely no right to talk.
September 27th, 2011 | 10:46 pm
Thank you, Lisa, for witnessing to this problem that is hidden from view from the patients and surrogates of elderly patients on Medicare/Medicade/TricareforLife and supplementary Medicare policies. You are a good daughter and you speak the truth!
We went from a culture where everyone was urged to know how to do CPR and save lives to a culture that preached that CPR is very bad for old peoplel I believe the nurses who help to spread the word about how bad CPR is for old patients are educated to believe that they are doing the right thing when they urge surrogates to let their loved ones go sooner, rather than later. They know, of course, that hospitals very often are not being reimbursed for ICU time for elderly patients. They are educated to believe that “futile care” is “fiscally futile” and bad for the bottom line of their employer. Nurses, like physicians, rationalize that the poor quality of life for the patient doesn’t justify extension of the old patients’ lives and, lastly, of course they follow the physician’s orders.
It is the Doctor, only, of course who has the authority to put a DNR/DNI in the hospital chart or to order the nurse to do so, under hospital policy BUT under law the Doctor doesn’t have the authority to do this without the consent of the competent patient or the surrogate of the incompetent or unconscious patient.
Hospitals use the permission NOT to do CPR to hasten the death of the elderly knowing, I believe, that most lay people think of CPR as bringing the patient back after they are already dead — and not of withholding procedures or withdrawing procedures that will keep the loved one alive!
It is driven, of course, out of the desire to save money and protect profits in the delivery of end-of-life care for the chronologically old whose shorter life expectancy (a co-morbidity factor) makes the elderly patient a target for budget restraints.
The whole idea of Hospice and Palliative Care was primarily for the purpose of keeping old patients from dying in Acute Care Hospitals’ ICUs at great expense to the nation’s private insurers and the federal and state governments.
Spread the word. Don’t give up your rights under the law to full-code care in the hospitasl by authorizing the physician to put a DNR in the chart UNLESS you really want to die SOONER rather than LATER.
September 28th, 2011 | 10:14 am
With something like abiraterone and the wide disparity of results, it may be simply that there are subtle differences between the cancers or patients such that some respond better than others. If those differences can be detected, abiraterone (and other drugs) would be used only in those for whom it will work. Five years is pretty good. Six months or a year is also really good. And while cancer treatment is generally harsh, it is not universally so.
Greater effort must also go into earlier detection and prevention, so that fewer treatments as desperate as “anything for a few more weeks” are needed.
September 28th, 2011 | 1:35 pm
[...] we accept the futile care premise, it won’t stop there. Indeed, as I have repeatedly shown, the idea of unilaterally refusing wanted efficacious treatment based on quality of life [...]
September 28th, 2011 | 2:33 pm
David:
If you feel that the US is lacking in resources and that some people need to die so that others may live, feel free to make that sacrifice yourself. Leave me and my loved ones out of it.
September 28th, 2011 | 8:04 pm
When the Hippocratic Oath falls to a panel of money laundered objections the balance between bioethicists & money broadens till compassion & patient care will disappear. During our lifetime in Canada we paid big taxes for health care when we were HEALTHY. Now such panels would file me under dead rather than cough up the money for the health care that I bought and paid for.
October 6th, 2011 | 8:30 pm
[...] And note, these bureaucrats are going to decide what benefits are worth covering financially. Terminal cancer patients beware! As one possible example, this could mean no coverage for life-extending chemo therapies–as [...]
October 19th, 2011 | 6:56 pm
[...] With Obamacare seizing control of deciding coverage issues nationally, we are on the way to our own verson of NICE. Indeed, Donald Berwick, the short timer head of Medicare has extolled the agency. Former Senator Tom Daschle, one of the most influential advisers to the president and Congress on Obamacare, also is on record wanting us to follow the path blazed by NICE. We are already rising support among the medical intelligentsia for rationing life-extending cancer treatments. [...]
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