Andrew Sullivan points to a live-chat hosted by Atul Gawande on his New Yorker article, Letting Go: What should medicine do when it can’t save your life?:
The fundamental issue I found … was not the percentage of people at the margin who really do want to spend their last days on a ventilator with a feed tube and dialysis machine, or getting knocked down by a fourth round of chemotherapy with a minuscule chance of helping. Perhaps there ARE more of these folks in America than elsewhere. But the crucial problem is that for most people, this is misery. They don’t want this when they really get down to thinking and talking through it. The failure of our system is that we are not good at helping people sort out what is most important to them when they are dying and then helping them achieve it.
Says Andrew, “And this was one crucial and important reform in the health insurance bill – killed of by Sarah Palin’s lies.”
Gawande also discussed his article this week on Fresh Air where he was asked about the characterization of end-of-life counseling as death panels:
GROSS: Now, the kind of end-of-life conversation that you were talking about earlier that you think doctors should have with patients – in which the patients and their families can clarify what they want the end of their life to be like and what physical compromises they’re willing to go through in order to have treatment and what they don’t want to go through – are those kinds of conversations the things that were described as death panels during the debate about health insurance?
Dr. GAWANDE: Yeah. The – I mean, it got mutated into that. The health reform bill had funding to have those kinds of discussions. These discussions at the end of life are long, they’re multiple, and sometimes they’re not with the patient themselves, but with the family members.
I describe one oncologist discussing the care for a 29-year-old with a brain tumor that was at end-stage. And he’d been through two rounds of chemotherapy and radiation, and he was ready to stop, but his family wasn’t.
And the oncologist had separate visits for the father – actually visited the father at home and talked through, you know, every possible option and what ultimately needed to be done, which was that the family needed to be there for their son.
And that’s not covered by insurance. You know, she said to me: I can’t tell you how much easier it would’ve been to just sign him up for another round of chemotherapy – and, by the way, she would’ve been paid better.
The health reform bill had a provision to allow for these doctors to have these conversations and fund them for them to happen, and it was stripped out because of the argument that this amounted to a death panel. …
The most fascinating thing about it, though, is that we see this as all about tradeoffs. You know, are we going to give up $80,000 drugs that would give us two months of life? The reality is that at the end, the way we care for people probably worsens their life and shortens their life.
A study of 5,000 Medicare patients that match people who chose hospice against people who didn’t choose hospice found that those who chose hospice didn’t die any sooner than the people who chose to stick with going to the hospital and so on.
And furthermore, for conditions like lung cancer and heart failure, those patients actually live longer in the end, by weeks – in the case of heart failure, three months longer, and that reveals to us that we have some dysfunctional decision-making towards the end, where that fourth round of chemotherapy is certainly not buying them time and is probably stealing not just quality of life, but stealing time from people.