Why They'll Pull the Plug on Grandma

We at Scragged wonder whether our lawmakers realize just what a hornet's nest of controversy they've unleashed with their pending federal takeover of health care.  They may not care, of course.  It seems that Nancy Pelosi doesn't mind sacrificing the careers of 20 or 30 "blue dog" Democrats who oppose her wildest "big government" dreams by forcing them to vote for an unpopular health plan.  A feminist recently wrote of her disgust that the Democrats were willing to sacrifice abortion rights merely to gain more power over health care.  If the Democrat's concern for health care is in fact a pure power play, they won't mind the resulting controversy at all because taking over the medical system will give them more power and more campaign contributions.

Anyone who actually cares about health, however, ought to be concerned with the government assuming the power to decide which treatments will be available after the bill takes effect.  With power comes responsibility, unless it's government power.  The bleeding-heart media who've celebrated Mr. Obama's every mistake as if he walked on water will be able to avoid writing about the people who'll die for want of treatment under the new plan and celebrate cost-cutting instead.

End-Of-Life Care is Costly

The dilemma of whom to treat and how aggressively has been around since the 1890's, but it's only recently been brought to public attention.  The New York Times reports:

This is an important issue, particularly since Congress has spent so much energy promising to save enough money to cover all the people to whom they want to give free health insurance.  Taxpayers are going to be quite unhappy if medical costs explode as many commentators predict.  End-of-life care is going to be examined closely because 7 out of 10 Americans die from chronic diseases such as diabetes or heart failure.  Most medical spending on such patients falls in the last two years of their lives both in the US and in Britain.  Medicare would save billions if all hospitals were able to reduce their spending levels and get closer to the Mayo Clinic spending pattern.

Some Patients are Helped

One of the difficulties with the Dartmouth study was that it focused on people who had died.  Any study which includes only people who die will tend to show that medical treatment is being wasted.  The Mayo Clinic explains their lower costs by pointing out that their doctors are salaried and don't make any more money from ordering extra tests or treatments.  Other hospitals retort that their populations may be sicker than the middle-class people who use the Mayo clinic.  The Dartmouth study did not include any medical records, so it's not possible to compare the health of the patient populations.

Prof. Fisher's argument that the patients they examined were all dead doesn't prove that they couldn't have been saved by more aggressive treatment, of course.  Without examining their medical histories in detail, his assertion that it's "unlikely" that differences in their illnesses would have made a difference in the cost of treating them is no better than a guess.

Another Times article describes the U.C.L.A. medical center whose costs were the highest in the Dartmouth report.

The "preserve life at all costs" ethos means that some marginal patients will get well instead of dying, albeit at great expense.  The Times describes a patient who was referred to the UCLA center for a heart transplant.  The doctors did a great many tests, changed his drug regimen to adjust his water balance, and even pulled some teeth which were causing infections.  After six months, he was able to leave the hospital without needing a fantastically-expensive heart transplant.  This patient survived, so the cost of his six-month hospital stay wouldn't show up in the Dartmouth study.  UCLA points to cases like his to justify their cost is no object, "we won't let you die" philosophy.

On the other hand, some medical folk say that more spending can lead to worse care:

In fact, expensive care is often worse care, because it snowballs into what some are calling an "epidemic of overtreatment," in which unnecessary procedures, tests and medications all spawn more tests, more meds (to treat the side effects of the first batch) and more follow-up scans and procedures (in stand-alone clinics owned by the same doctors prescribing the tests, scans and procedures).

This controversy cannot be solved for the population at large.  Depending on which sets of patient data you choose, you can prove nearly anything you want to prove about medical care because different groups of patients vary so much.  Thus, for each individual patient, decisions ought to be made by the patient in collaboration with the medical people who're assigned to the case.  If medical care were like any other service, that's how decisions would be made.  The problem lies in the fact that the patients aren't paying for their treatment.  He who has the gold makes the rules, of course.  Since the patient doesn't have the gold, the patient doesn't get to make the rules.  The more government money is involved, the more heavily government plans, policies, and procedures control treatment decisions.

"We won't let you die" represents the dying gasp of the traditional medical oath of serving the patients' interest which doctors used to swear on entering into professional practice.  The Dartmouth study represents a new wave of thinking about medicine.  Under this idea, which is being cast into law, the medical system should serve the interests of society instead of serving individual patients.  If a given patient's life doesn't promise enough social benefit to be worth the cost of treatment, the patient won't be treated.  This philosophy treats political elites better than the masses.  After all, our leaders reason, their lives are worth a lot more than ordinary people's lives are worth; they deserve better medical care than the masses get.

This is an extremely slippery slope.  In the not too distant past, subjective judgments about the intrinsic worth of black people's lives were used to justify enslaving them.  In the brave new world of federalized medicine, subjective judgments about the value of sick people's lives will be used to justify not treating them.  There are huge amounts of money involved, of course, which makes the siren song of denying treatment that much harder to resist.

Help Comes at a Cost

If the Mayo Clinic saves as many patients as the UCLA medical center and they're equally sick, then UCLA's extra $25,000 per patient is wasted money.  If, on the other hand, the UCLA center is curing sicker patients, Mayo needs to spend more money, an unpalatable conclusion in these times of huge deficits.  Since the Dartmouth study came out, a group of California hospitals conducted a study which seems to show that with respect to cardiac patients, hospitals that spend more money had higher cure rates.

Studies suggesting that the nation should spend less money on mammograms caused a political storm.  Mammography is a relatively simple, well documented procedure compared to cutting-edge treatment for cancer and heart disease.  The storm over mammography is as nothing to the controversy that will come about as Obamacare tries to cut back on costs by denying treatment to old people who're thought to be on their last days.

Expectations Matter

Part of the problem is based on patient expectations.  Mr. Obama told us how his grandmother fractured her hip at a time she had only a few months to live due to cancer.  He pointed out that if the doctors had refused her a hip transplant so that she'd be a helpless cripple in permanent pain for the rest of her life, he and her other relatives would have been more than a little upset.

When an old person is dying, none of the relatives wants to be the first to suggest that doctors pull the plug on grandma.  What's worse, treatment doesn't cost the family any money, they have no notion of cost, and nobody talks about the pain that might be inflicted on grandma by more tests and treatments.

We have a good friend whose 89-year-old mother died unexpectedly.  She didn't show up for an activity, so her nursing home staff went looking for her.  They found her unconscious and rushed her to the nearest emergency room.

My friend was driving to a meeting when his cell phone rang.  The ER doctor wanted his authorization to send his mother to a different hospital where a neurosurgeon could try to plug the leak in one of the blood vessels in her brain.  He asked where the leak was.  When told it was deep in the brain, he asked whether there was any realistic chance of a workable repair without damaging the part of the brain that housed her personality and character.  When he was told, "No", he told them to pull the plug.

The doctor later called him to thank him for not putting his mother through a painful, hopeless procedure.  Most families want the doctors to battle to the very end, no matter how hopeless, painful, or expensive the situation.  My friend knew enough about the brain to know that even if her body didn't die right away, his mother would never come back from having her brain shoved around so they could get at the leak; he authorized the doctors to let her go.  Few relatives are as well-informed and doctors have a hard time getting such concepts across to distraught relatives.

We Will Pull the Plug

The New York Times put it thus:

And if you think reform is tough today, just wait. We're already practically a gerontocracy: Americans over 50 cast over 40 percent of the votes in the 2008 elections, and half the votes in the '06 midterms. As the population ages - by 2030, there will be more Americans over 65 than under 18 - the power of the elderly and nearly elderly may become almost absolute.

In this future, somebody will need to stand for the principle that Medicare can't pay every bill and bless every procedure. Somebody will need to defend the younger generation's promise (and its pocketbooks). Somebody will need to say "no" to retirees.  [emphasis added]

The only way to save money given all the new people we're promising to treat is to reduce treatment for people we're treating now.  As a society, we're going to have to pull the plug on grandma, and on anyone else for that matter, when it looks like he or she won't make it.  Unfortunately, it turns out to be extremely difficult to decide when a patients' last, say, month or even week has started.

The British have been rationing health care a lot longer and a lot more severely than we have.  Their experience with various ways of saving money by not treating elderly people, sometimes by telling them they have a duty to die, helping them commit suicide, perhaps by treating them poorly, and sometimes by not treating them at all, tells us how our system will work once our bureaucrats get settled into all the juicy new jobs created for them by the pending health bill.

In "Daughter saves mother, 80, left by doctors to starve," Timesonline reports:

AN 80-year-old grandmother who doctors identified as terminally ill and left to starve to death has recovered after her outraged daughter intervened.  [emphasis added]

Hazel Fenton, from East Sussex, is alive nine months after medics ruled she had only days to live, withdrew her antibiotics and denied her artificial feeding. The former school matron had been placed on a controversial care plan intended to ease the last days of dying patients.

The National Health Service had instituted a "no treatment" policy aimed at saving money during a patients' last few days or weeks of life.  The daughter was convinced that her mother wasn't dying, but she had to fight the hospital staff for "weeks" to get them to start feeding her mother again instead of letting her starve.  The lead nurse for the program reports that 3% of the patients placed in the program recover despite not being given the usual treatment for their conditions and being left to starve or dehydrate instead.  Now if we could reliably identify those 3% patients who'd get well without any treatment at all, we'd really save money.

It's obvious that the only way to encourage hospitals to be more efficient is for patients to spend their own money.  Given that our leaders chose not to shift more medical costs to patients who might have some chance of influencing prices downward, treatment costs are going to go up, particularly as hospitals become federal facilities and unionize.  No government bureaucracy in the world has ever been able to cut medical costs other than by rationing and letting enough people die to stay within the budget.

Unless we assume that American bureaucrats are a lot wiser and a lot more medically sophisticated than British bureaucrats, which is most unlikely, they're going to relegate people into the "no treatment" category who'd recover with better treatment just as happens in Britain now.  Killing off sick people by not treating them will certainly save money, cutting both medical costs and Social Security payments.  This may not be where we want to go, but it's where our lawmakers are taking us.

Bureaucrats will pull the plug on grandma when she gets too expensive.  Our politicians know this, which is why they elected to stay with their Cadillac program for which we pay.  Stand by for a rough ride when this becomes clearly understood by grandma's loving family and her surviving friends.