A good thing for once: May 5, 2008
Posted by keepbreathing in death, ethics, gomers, health, health and wellness, medicine, opinion, respiratory therapy.trackback
For once, news about healthcare that seems to be positive. I refer to an article in todays Times about Kendal at Hanover, a nursing home affiliated with Dartmouth-Hitchcock Medical Center way up in New Hampshire.
Kendal at Hanover is apparently not your usual nursing home. For one thing, they apparently focus on giving the elderly a choice in medicine that they may not even know they have: the choice to say “no.” According to the article, the staff at Kendal are very assertive in speaking with residents about the choices they face at the end of life and the implications of those choices. I quote (emphasis mine):
Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.
At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.
Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.
A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”
First: the right of patients to refuse treatment. This is a right that I think many patients don’t even know they have. I can’t count the number of times that people have demanded to know why they “have to do this,” only to be totally surprised when I tell them that they have a right to refuse care. The principle of patient autonomy dictates that we should not force treatment upon people who do not desire it, and while we are very good at following this principle most of the time I think we could do a lot better if healthcare providers were a little more aggressive in informing people that they have a choice.
We could also do a little better about talking to the families of those who have been incapacitated. Often, families make a choice that the patient would not want because they are not ready to let go. This is a difficult situation at best, but what the patient wants should come first; the family is an afterthought.
Second: death by intensive care. This describes probably half of what we do in the ICUs where I work. We have a lot of patients who are just in the ICU transiently: septic people, surgical mishaps, recovering heart surgeries, trauma patients, and so on. These people will recover and leave. But we also have a lot of chronic elderly patients who are going to linger in the ICU for several months and then die. We can animate a slab of carbon for quite some time, but just because we can doesn’t mean we should. I can’t speak for everybody, but when I die, I don’t want the last two months of my life to be spent in an ICU. That’s no way to go.
In conclusion: I like the idea of Kendal at Hanover. I think that we in the healthcare industry should follow their lead: we should lay out the fact that everybody dies and then offer people control over the end of their own lives. Pretending that medicine will keep everybody alive forever is only going to make it worse. Mortality is a fact. We can either hide from it or face it head-on, but we will never escape it.
“Often, families make a choice that the patient would not want because they are not ready to let go. This is a difficult situation at best, but what the patient wants should come first; the family is an afterthought.”
You are absolutely right, as usual. So why doesn’t it work that way? Simple; when the patient dies, it is the family, not the patient, who sues us because, “they just let grandma die and didn’t do ANYTHING to save her!” Juries eat this up. They think competent care means “do[ing] everything for grandma,” that the more treatment a patient gets, the better off they will be, and anything less than everything is negligence. If they only knew. However, they don’t, so our poor patients will continue to suffer unnecessarily.
Slow medicine and the right to say no.
Wow! I would say this evolving concept is a grand one.
You always have excellent points about end of life care. I really agree with you that there should be more education available to the patient and family too so a patient doesn’t have to end his life like this. However, the medical bureacrats whose paychecks would be diminished if this patient didn’t spend all this wasted time in the hospital would shun at you even mentioning this. By golly we need sick people so we can bill their insurance agencies or the Fed or whomever.
That’s about what it comes down to, or so it seems. I’ve had this discussion with the mother queen bee here at Shoreline, and the bottom line is we need patients to make money. It’s far easier not to bring it up. But, man, I agree with you 100% on this.