Is Hospice Care Really Worth It?

The current technologically driven medical culture in the United States has marginalized dying patients. With today’s respirators, blood filtration systems, cardiac pumps, feeding tubes and other life sustaining machines, doctors are able to preserve the life of human cells—and I mean that literally. We have become exceptionally good at providing human cells with the necessary oxygen and nutrients to sustain them. We are able to keep someone alive as essentially a cell culture. What is often put to the side is the fact that if these measures were not taken, the patient would likely die. No one has been able to figure out how to be immortal yet. Part of human nature and the cycle of life is death. While extending life has become the norm, it should not outweigh the inevitable fact that all humans die. It’s is undoubtedly hard to talk about—no one wants to die, but it is a reality that all of us will have to face at one point in our lives. This “human cell culture” attitude to healthcare has caused less patients to enroll in hospice care. Hospice care should be more widely used, frankly. At the end of life, we have developed an unfathomable ability to sustain life, which has come at the cost of quality of life. Hospice is often seen as a death sentence, in the words of my grandmother discussing her friend’s recent hospitalization. But it begs the question, is a hospitalized death so much better? Is paying an absurd amount of money for a few extra months really worth it, considering the fact that the patient will largely be reduced to a hospital bed for the whole time? Seeing a loved one die is not an easy experience for anyone to go through, but I think that a family centered approach to death is the best route. Hospice care allows maximum family time, which should never be marginalized.

Process Reflection

As the class winds down, I have started to realize how much I have learned. In the beginning of the semester I had my opinions about the heathcare system from my own point of view, but now that the semester is almost over I’ve been exposed to not only the facts, but to a myriad of different opinions about possible solutions. One thing that this course has taught me is the importance of critical thinking. It has taught me that what people say is true may not actually be as true as one thinks. It is absolutely crucial that we gather objective data and analyze it with as little bias as possible. In the healthcare system, this observation becomes even more important because of the sometimes fierce debates about politics and morality that can arise when talking about healthcare. I hope to take that kind of thinking into my courses in the future. In today’s emotion-driven world, the importance of fact has become even more important than in the past. I have learned to hear about someone’s position and look at the data they present, and determine the validity of their argument and think critically about the issue. This type of independent thinking is often ignored. But thankfully this class has helped me to calm emotion and voice opinions and facts to effectively present an argument. That kind of emotional, opinion-based topic is hard to find in my major, and I am grateful to be given the opportunity to take the course. It has inspired me to think critically about the medical system and profession. Hopefully I will carry what this class has taught me into my future profession.

The Importance of Consent in Treatment

Although I have largely disagreed with Weitz’s position in the past, I believe that on the whole she is accurate in her piece “Watching Brian Die.” The importance of consent of treatment is becoming even more important. Doctors can sometimes get carried away with doing everything they can to sustain life. This, however, is a case study. Dr. Thomson is likely an experienced physician that understands the necessity of legal documentation prior to treatment. If for example, the family were to deny that they said Brian did not want to live if severely disabled, he would be in serious trouble if he stopped treatment. The lack of a living will or a DNR or some kind of terminal care is crucial in the decision-making process. By all means I don’t mean to say that the manner in which this specific doctor conducted himself is commendable. I simply mean that legally the only thing he could do was to treat him. I think that especially in today’s over sensitive, sue at the drop of a hat world, he was most likely covering all of his bases. The solution to this kind of problem is simple I think. As soon as one is married or a legal adult, create a living will or at least some kind of documentation that describes end of life procedures, especially if you work in a hostile environment. It will only take a few hours or maybe even a day or two. Its worth it. It will allow your family to have peace of mind and avoid fighting over what they think is right for you.

Patient Rights are Second to Survival

Zussman proposes some interesting points. He laboriously mentions the conditions of intubation and sedation among patients in the intensive care unit. What he fails to mention, however, is that the majority of these patients require these types of treatments. Patients are never intubated to stop them from speaking or to hinder their rights. Patients are placed under these harsh conditions for good reason. When someone is intubated, it is because they are likely to have respiratory compromise. Respiratory compromise is a life threatening problem. No one has figured out how to live without breathing quite yet. The intensive care unit is the place for severely life threatening diseases/problems so it should not be surprising at all that such a high number of patients are intubated upon arrival or prior to coming to the ICU.
The primary function of the ICU is to preserve life. Oftentimes patient’s chronic issues are overlooked to ensure vitality. Zussman mentions and scorns doctors for overlooking chronic issues. He mentions specifically that a doctor will treat a GI bleed but ignore the colorectal cancer that caused it. What else is he or she supposed to do? Time in the ICU is very expensive, not to mention that if the GI bleed is not controlled the patient will die much earlier than from the cancer they have. Zussman is attempting to apply patient rights in a situation where their life is in critical danger. I like to think of it as a two tiered system. At the bottom is the likelihood of long term survival. Then above that is patient’s rights. When the patient is likely to die from respiratory failure or a GI bleed at any moment, taking a history and figuring out if they have a family history of kidney disease or colorectal cancer is not helpful at all. Those elements of the patient’s profile become infinitely more important only when the patient’s life is not in immediate danger. Whether or not we know if a patient has colorectal cancer now while they are losing significant blood will not effect their likelihood of survival. No one has figured out how to cure cancer in a day. Zussman tries to raise the question of patient rights in the ICU, but the fact of the matter is that (and this is assumed under implied consent, until the physician is presented with a valid DNR order) the staff has a moral obligation to do everything in their power to ensure life. And sometimes that comes at the expense of patient’s rights.

Chimps in Medical Research

The use of animals in medical research capacities has been an active topic of debate for decades. Just recently, however, the National Institutes of Health stated that they would end all federal support of invasive research on chimpanzees. There has been a lot of controversy in recent years regarding the use of non-human primates. The NIH has retired 183 chimpanzees to a federally funded sanctuary in Louisiana called “Chimp Haven.” The NIH also has stated that they intend to send 308 more chimpanzees to the facility soon. Several years ago, the NIH reduced the number of research animals to 50. The rest of the primates were not used in invasive research. The NIH revealed that they intend to send those primates to the Louisiana facility soon as well (as part of the previously mentioned 308). The ban put in place by the NIH is both beneficial and detrimental.

Evidence has shown that certain types of research on chimpanzees were largely ineffective. A report was published that led the NIH to retire a significant amount of its research primates. The NIH then instituted stricter requirements for using primates for research. Chimpanzees also were recently deemed endangered and placed under the U.S. Endangered Species Act. The director of the NIH, Dr. Francis S. Collins, stated the NIH has found “no evidence that there is a need to continue to do research of an invasive sort on chimpanzees, not now and not going into the future.” The report, however, does not call for an outright ban on research with chimpanzees—simply invasive procedures. Pharmaceutical companies are still able to test drugs and other treatments on chimpanzees, as long as they do not involve invasive measures (such as needles, catheters, or other instruments). The ban on invasive research is not all good however.

Some may argue that this is another measure by the NIH in a stream of recent restrictions placed on medical and basic research. In the last few months, the NIH has restricted its funding on heart research to only those studies that propose beneficial outcomes to patients. It has severely cut its funding for basic research. Again, the NIH is restricting the use of animals in a research setting. Although the specific type of research banned has been shown to offer no benefit, this may provide precedence for future restrictions on animal research. What will the next restriction be? Is it possible that the NIH defunds use of ferrets for immune research? What about mice for drug research? Could we have to result to single cell organisms for our drug testing? These are questions that are worth asking. Without animal testing the best we can do is to test drugs on individual cells, which may or may not correlate to how the drug works in vivo. The leap from a yeast cell to a human organism is vast and frankly illogical. That may be an extreme exaggeration, but it is worth considering. How do we balance animal rights and a genuine need to test drugs before possibly harming humans? My answer is to take an evidence-based-medicine approach to the situation. Extensive study should be used to remove an animal from medical testing. We should invest in studies to find out if testing on certain animals is necessary and beneficial. If not, then we can defund those studies. If they are, then we should continue to support them. This is a fine line to walk, but it is of pivotal importance that we do not sacrifice ourselves in the process.

http://www.nytimes.com/2015/11/20/science/nih-to-end-backing-for-invasive-research-on-chimps.html?ref=health&_r=0

The Importance of Objectivity

Grooperman, in his book “How Doctor’s Think,” highlights the importance of objectivity. By this, however, I do not mean to suggest that a physician should look at the patient as a set of numbers, or images, as is commonplace in today’s technologically centered medical environment. Instead, the doctor should look at what is presented to them and diagnose based on what they observe. Part of that, however, is to let the patient talk through what they are feeling and experiencing. We talked in class about how some medical schools have adopted an art appreciation course into their curriculum. I think that that type of analysis is exactly what doctors need to pursue and is analogous to what Groopman is arguing. A spectator does not have the luxury to ask the artist what they meant to convey in a painting. We cannot always talk to them and have them tell us what the painting means. We are left to simply look at a painting’s details and interpret the meaning. Physicians, in a similar manner, are left alone to look at the facts that are presented to them (by tests and the patient) and develop a diagnosis. Groopman asserts that asking open ended questions is of principal importance. Open questioning is a technique to extract unbiased information from what the patient experiences. If one were to ask if a patient had radiating pain, they might lump their current experience into the “radiating pain” category. Instead, if one were to ask a patient to describe their pain, the physician may get an entirely different answer that draws them away from one diagnosis and directs them to another. Without a doubt, asking the right questions is important, but it is arguably more important to ensure that they are not suggesting a correct answer to the patient. In the case of Anne Dodge, Falchuk decided to formulate his own opinion based solely on what she said. He decided to look at the whole canvas of her experiences instead of what other physicians had said. This kind of directed, biased questioning can lead doctors to horribly inaccurate diagnoses, which can diminish the health of the patient. A physician may have an algorithm to follow in order to affectively diagnose a patient, but I think that these are meant to be kept secret from the patient. A doctor should allow the patient to fill out the algorithm sheet without seeing it. A doctor may ask questions to direct the conversation, but they should not be to simply get the answers to a checkbox form. Objectivity in letting the patient tell their story is of principal importance, regardless of the power of technology. How will the future of medicine develop with the advancement of technology? No one is entirely sure, but one thing is certain: we cannot forget that people are more than statistics, numbers, and images.

A New, Life-or-Death Approach to Funding Heart Research: A Fundamental Mistake

In recent years, federal research funding has been drastically cut. According to Francis Collins (NIH director), “we are throwing away probably half of the innovative, talented research proposals that the nation’s finest biomedical community has produced.” Due to federal budget cuts, researchers today are having more trouble than ever before to find funding. Even the most crucial studies to human health are being sliced. In fact, “studies show that 18% of young scientists are considering moving to other countries to continue their research.” Is that really what the United States wants to do? We often claim that we are the most technologically advanced country in the world and that the research produced in the U.S. is unparalleled. Yet, for some reason, we continue to ask scientists to operate on less and less money. Many scientists are out of work simply because they are unable to find funding for their projects. With a reckless spending of government money going to various unnecessary programs, research has taken a huge blow. And for some reason, the government has decided to take even more money away from research.

This specific article praises the NIH in stating that “the result [of the new budget cuts] will be the financing of fewer, but deeper, studies, to focus resources on efforts with real-world impact and life-or-death implications.” Who determines that? Who has the power to say that the research that one scientist is doing, on transcription factor behavior and mutation for example, is somehow less important that another scientist working on immune cell function? The most fundamental goal of science is to determine and understand the unknown. How can one person or group rationally undermine the very essence of the scientific method and choose to fund only projects that they believe will have some kind of beneficial outcome? The fact is that they cannot. Some projects, rightfully so, go without funding simply due to insufficient evidence or lack of organization or other similar reasons. Choosing not to fund a project because it does not have immediate return is illogical and counter productive. If for example, Mendel’s research on genetics were up for funding in today’s environment, I am not entirely sold that he would even receive funding. Mendel is the father of modern genetics. He hypothesized the most basic causes of genetic inheritance, which is just now leading to advanced study. Mendel’s research had absolutely no immediate impact. No one was immediately cured of typhoid, tuberculosis, measles or mumps or anything because of his research. What his studies did do, however, is open the eyes of millions of scientists of the future to the most basic mechanisms of genetic inheritance. These kinds of studies cannot and should not be ignored. The importance of basic research is crucial. Without a strong foundation of understanding, future studies are useless. We cannot study the mechanisms of DNA repair without first understanding that DNA is the genetic material of life.

We do not understand the full function of everything. Granted, we know more than we did even a decade ago, but there is still so much that is unknown. Targeted studies should receive funding, without a doubt, but let’s not forget that these studies are built on basic research. If we do not fund basic research now, we will be nowhere when the current targeted studies fail or another problem arises. One thing that the NIH is doing right, however, is offering a database for unpublished data. Positive data (studies in which a relationship is observed and confirmed) are arguably just as important as negative data (studies in which an observation has been seen to not be caused by something). The publication or storage of negative data allows researchers to narrow their focus to things that have been suggested to work, and effectively lowers costs.

The selection of research based on the immediate life-or-death consequences is inappropriate and hinders innovation. Studies should not be only funded for their likelihood to immediately cure a patient. Basic research is the foundation of scientific knowledge; without it, our entire American research prestige disappears.

http://www.nytimes.com/2015/10/20/health/a-new-life-or-death-approach-to-funding-heart-research.html?ref=health

Education as the Solution to the Fundamental Causes of Health Inequalities

In their article “Social Condition as Fundamental Causes of Health Inequalities,” Phelan, Link, and Tehranifar expose us to Fundamental Cause Theory. The Theory suggests, quite accurately it appears, that there are inherent social factors (socioeconomic status specifically) that correlate with overall health and healthcare access. This idea may seem simple, yet it has persisted throughout time. One proposal that the authors put forth is a mass redistribution of resources to nullify the inequalities. At first it seemed like a good idea to me, then I started to think about how that would effect everything else. Simply raising lower income people’s pay will not necessarily lead to them saying, “you know, I should spend this money on my health.” Considering that smoking is significantly more common among lower income populations, it’s entirely reasonable that they might buy more cigarettes, go out more often, and spend the money lavishly instead of investing in their health. This is a problem with all populations. The problem that I just described is one of education. Instead of pointlessly giving money to lower income populations and expecting them to think of their health first is going about the solution in the wrong way. Instead of providing resources first and expecting an outcome second, we should, in my opinion, give people the information that they need in order to make smart decisions with their money. We cannot help the lower income people by throwing money at them (as many wealthier populations tend to do). We need to invest this money in educational programs in schools, community centers, places of worship, etc. The more people that learn about the consequences of actions would result in more people taking an active role in the maintenance of their health. This, however, is not a complete solution. Some people will still be unable to improve their health, despite how educated they are. In the increasingly common “food desert,” for example, whether or not someone is educated about their choice in food has no effect on their ability to access quality food. Throwing money at the situation may look good on paper, but it would never be effective in isolation.

Process Reflection

Before taking this class I never really knew about the healthcare system. I had marginal exposure from my parents who work both on the business and patient side of medicine. I knew that healthcare was expensive, but I never understood why. I had always assumed that the healthcare in the United States was just more expensive than anywhere else. I never questioned anything. Now that I have been in the class for a few weeks I have begun to realize how complex the system is. It’s not just doctors over prescribing, over imaging, etc. One huge part of the puzzle is the culture that we live in. Patients demand that everything be done to help them, even when that “help” may not be applicable or necessary. But the patient demand isn’t the answer either. Pharmaceutical companies play a major role too. It’s a combination of a myriad of factors that contribute to the immense over use and over spending in our system. The exposure this course has given me so far has caused me to question the healthcare market more than I would have ever expected. The information presented in class, in addition to the readings, has provided me a means to develop my own opinions about policies. As someone who wants to go into the medical field, I think it is crucial to understand the healthcare system. Being a physician today is completely different from how it was a few decades ago. Doctors today should not only be fluent in the science of medicine, but they should also, to a certain extent, understand the complexities of the healthcare system. Especially in today’s world with so many players involved, the modern physician needs to speak the language of the healthcare system. I think that this course provides a necessary service to everyone, not just those who wish to make a living in healthcare.

Transgender in the Cancer Clinic

In today’s times, people in the United States are more free than ever to express themselves. No longer do people have to hide behind the many stringent social norms. The great societal-acceptance shift brought on in the last decade has finally made its way to medicine. In this short article, Dr. Mikkael Sekeres, the director of the leukemia program at the Cleveland Clinic, mentors a fellow through (presumably) his first interaction with a transgender person. The patient report—complaint, medical history, allergies, medications, family and social history, physical exam and results—was entirely accurate and just like every other one the fellow had given. The only thing that differed from the standard was the sex of the patient. It was entirely absent from the report, with good reason. The external output of the patient did not match their internal biology, so, understandably, the fellow was uneasy as to which sex to assign.

The patient presented with chronic myeloid leukemia, which occurs when chromosomes 9 and 22 translocate genetic information that leads to nonstop cell proliferation. In the genetic workup of the patient it was determined that they were XY, or genetically male; however, they identified as female. This type of patient presents an interesting new type of challenge to the modern physician. Physicians, despite the dehumanizing classifications that have been given to them, are scientists first. That’s exactly where the problem arises. According to the most basic determinants of a person’s sex, the patient is undoubtedly male, but the external projection of the patient did not match its biological origin. So how is a biologist supposed to approach this? The thing is that a physician is much more than a biologist. Much more than a scientist, an evil businessman, a greed-filled person that cares nothing for his or her patients. They are people too, let’s not forget that. And like most people nowadays, they are accepting of others.

Dr. Sekeres did what he would with any other patient. He examined her, asked her questions, and treated her just as he would any other person. That’s the ultimate victory of equality. It’s not recognition of someone’s difference from social norms; it’s the exact opposite. It’s ignoring what makes them different from what society determines as normal. In the fellow’s report, he used both male and female pronouns to discuss the patient. Later on, Dr. Sekeres went into the report and changed them all to female. Unlike some of his peers in the medical community, Dr. Sekeres understands the difference between gender and sex. The sex is the biological and genetic information whereas the gender is a patient’s outward expression of themselves.

Although the medical community may be resistant to the societal changes brought on in the last decade, it is crucial that they accept patients for who they are. In the case of this patient, genetically male, but female. I think that, in terms of the treatment and care for the patient, the gender of a patient has nothing to do with it (but the sex of the patient might). However, when it comes to talking to and about the patient, it is crucial. I cannot imagine what it must feel like to identify as female and be referred to as “he,” or “him.” It must be hard, which is why physicians must pay attention to these types of things. Patients are more than biology. Patients have feelings too. Let’s not forget that. At the end of the day, the treatment and care must be the same. That’s true equality.

http://well.blogs.nytimes.com/2015/09/24/transgender-at-the-cancer-clinic/?ref=health&_r=0