Friday, August 14, 2009

Section 1233 End of Life Consults

The strange thing to me about incentivizing the clinician through the payment system to do these consults is the Docs last guy I'd go to for end-of-life advice.

I'll ask the doc my odds --I ask the odds of going south on any intervention-- but my fear is a Doctor's "hero" training. He'll want to do extraordinary interventions because that's what he was trained to do.

Worse, I'll find myself an interesting case and he'll keep me going for research; a study for his paper (Chicago has a lot of academic medicine.)

I'd turn to my minister and others for advise on seeking or refusing more care; not my provider.


ogre said...

Nice theory--just bad fact.

I sat through a lecture yesterday talking about tracheostomies and medical ethics. The idea that the medical staff is going to be urging you to do anything merely to remain nominally alive is simply bogus.

One of the cases made it explicit--and showed the formal recommendation to the decision-making members of the family; Do Nothing More in the way of medical intervention. The point being that nothing that could be done would offer any plausible hope of benefit--no improvement in condition, no quality of life, merely the opportunity to continue on existing... and *suffering* pain associated with underlying conditions and almost certain experiences.

The medical advice -- do nothing. Let go.

The family decision -- do anything and everything, for as long as possible.

You're simply wrong, Bill. Yes, doctors are trained to do things that are astonishing and "heroic," but that doesn't mean that they're always a good idea. And the doctors, nurses, and hospitals are in the business of helping all involved make good--and ethical--decisions in such cases (please note; the hospital would get reimbursed, the doctor too... and the advice was DON'T. The bad decision was made by family--perhaps with religious advice, perhaps not (but the hospital chaplains are represented on the ethics team and agreed with the formal advice not to do anything)).

People indulge in amazing delusions and frantic, hoeful graspings that a miracle will occur, and then another, and another, and that in that case... hope might exist.

Who better to tell you that your chances are crap--or worse--and that you should consider nothing more than palliative care and the best quality of life for what remains? The minister can be supportive... but can't make that medical analysis.

Bill Baar said...

I expect the Dr to give me the odds. If I chose to decline more intervention, I expect palliative care. (Something they often don't do very well, because, well, they want to cure you, not give you a palliative).

I expect a Minister to help me with the ways to know when I should refuse more care when the doc gives me bad odds. I want some help from them on that one.

I just want the odds from the Doc. How I play those odds, and when to decide to cash in the chips if I'm faced with that... is something I want help from Minister, family, and friends.

PS I worked for a Boss once and I asked her if she ever told people exactly how long she thought they had to live. She told me she never does that anymore because she had a patient with a rare disease that caused his body to over produce calcium. It poisned him and there was no cure. She told him two weeks.

The patient stopped eating, which cut the amount of poison, and carried his life beyond two weeks and made him a very angry patient.

So she'll tell you only, if faced with your odds, you ought to talk to your minister, family, lawyer, and friends.

Bill Baar said...

PS I also listened to another Chaplain salaried at a large Academic Medical Center. He made an extensive justification of his work including the fact that he helped the largely African American patients deal with the fear of being experimented one. He was uniquely qualified to deal with African American fears.

I whispered to my boss that having seen Medical Research from the inside, I would be a little concerned about that too. Even fifty years after Tuskegee.... or however long ago it had been. This was a few years ago.

Docs and Medicine can do a lot for you. And I want a surgeon with the certainity of a fighter pilet. I don't want him seized with doubt as I lay on the table wiht my chest open.

But these guys are human... and often not well trained on deal with the human and spiritual sides of things.