Thursday, July 29, 2010

Medicine and "Death Panels"

Atul Gawande has a typically great article in the New Yorker on how our medical system deals with the end.  It appears that hospice care can be the most meaningful option for patients who are known to be terminally ill, yet few choose it.  To choose hospice care, most insurance plans force you to sign a statement that you consent to stopping treatment, which many people view as admitting defeat.  When they do wish to choose it, their families talk them out of it, not wanting to admit the advent of what's coming.  

 It has also been shown that when patients do choose hospice care, their life duration stays about the same as it does with intensive treatment.  In some cases, it is extended.  In all cases, the quality of life is much improved, reducing suffering for the patient, the patient's family and incidence of depression in loved ones.  But for a patient to choose hospice, the physician has to have a very delicate, deliberate, and extraordinarily difficult series of conversations with the patient and the family.  

Given how prolonged some of these conversations have to be, many people argue that the key problem has been the financial incentives: we pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise. This certainly is a factor. (The new health-reform act was to have added Medicare coverage for these conversations, until it was deemed funding for “death panels” and stripped out of the legislation.) But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.

More often, these days, medicine seems to supply neither Custers nor Lees. We are increasingly the generals who march the soldiers onward, saying all the while, “You let me know when you want to stop.” All-out treatment, we tell the terminally ill, is a train you can get off at any time—just say when. But for most patients and their families this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. But our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and to escape a warehoused oblivion that few really want.
 Read the full article here.

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