It’s a big mistake for conservatives to attack a provision in the
House’s health care bill that provides physician payment for
end-of-life discussions. Republicans John Boehner and Thaddeus
McCotter worry about “government-encouraged euthanasia,” but seem to
have no problem with our present situation: government-funded torture.
Every day elderly people in America suffer needlessly because they did
not discuss end-of-life issues with their physician. We don’t save
their lives; we prolong their deaths.
Consider a 90-year-old mildly demented man I met recently in the
intensive care unit. He was found unconscious on the floor in his
assisted-living residence. The emergency squad began resuscitation and
rushed him to the hospital where he was placed on a ventilator and
intravenous drugs to support his blood pressure and fight infection.
He had a blood-borne infection and was in shock. His organs were
failing, and he had no chance of recovery. I presented these facts to
his son with the certain outcome: your dad will die. I recommended
that he allow his father to die naturally. If he refused to agree to a
Do Not Resuscitate order, then we would be forced to perform CPR and
further prolong his father’s death.
The son needed time to think about the decision and contact his
brother. I pleaded with him to do that quickly and call me on my cell
phone. He never called, and his father’s heart stopped several hours
later. My staff performed CPR, not once, but twice over a period of
several hours until finally the sons told us to stop.
Shocking as it may seem, scenes like this are common in our hospitals.
Medicare paid the bill for the torture we performed on this elderly
man who never had the opportunity to decline these heroic, but futile
measures because no one had discussed code status with him before he
faced this life-ending illness.
Americans are grossly misinformed about end-of-life care, so they are
unable to make informed decisions. A study published in 2006 surveyed
patients over age 70 regarding their perceptions about surviving CPR.
Researchers asked them what they believed their chances were of
surviving resuscitation if their heart were to stop while they were
hospitalized. Eighty-one percent thought their chances of survival
were 50 percent or greater. The truth is about five to 10 percent. The
source of this serious misinformation was television medical dramas,
where successful resuscitations occur about 67 percent of the time
(1996).
The House Bill provides payment to physicians for end-of-life
discussions. Primary care physicians know their patients and are in
the best position to have these conversations. Unfortunately, the
current payment system discourages the difficult practice of
initiating end-of-life discussions. Payments are meager, and Medicare
refuses to reimburse physicians for any work that is not face-to-face.
How much phone time do you think it would take to arrange this type of
conference with a patient and his or her family? Now imagine doing
that for free and you will see one reason why these conversations are
not occurring.
We must pay primary care physicians to inform patients about their
end-of-life choices. It is a good first step toward helping elderly
patients make sound decisions. Much more needs to be done to educate
our public and medical community about the relative futility of
resuscitation in elderly patients.
One final tragedy drives the point home. Imagine that you are severely
demented and living in a nursing home. That means your short-term
memory is gone. It’s likely that you would be bed-bound. Now you
contract pneumonia. Would you want to be rushed to a hospital to treat
your pneumonia or would you prefer to be kept comfortable in the
nursing home and allowed to die naturally, if the pneumonia
progressed? It may be an easy decision for some, a difficult one for
others, but everyone should at least be allowed to make his or her own
decision. Most people I survey choose the comfort care route over
going to the hospital.
Here’s the tragedy: in America, 93 percent of nursing home patients
with severe dementia would be hospitalized in this situation (2007). I
can’t believe that all those patients would make that choice, given
the facts and the opportunity to refuse life-prolonging care. People
need the facts. For the sake of your future and that of your
loved-ones, investigate end-of-life issues. Write a living will, get a
power-of-attorney for health care, and be sure to discuss code status
with your physician.
Jeff Gordon, MD