Changing End-of-Life Care

After reading “Fighting to Honor a Father’s Last Wish: To Die at Home,” I have to wonder what could possibly be done to change our current system of elder care and end-of-life care. If the system continues to be largely run for profit, then we are never going to get to a point where we stop spending so much money on unwanted medical care and start investing more in social services. My questions revolve around that idea. What can be done to incentivize home health care and social services? For those who are truly too sick to be cared for at home, what can be done to improve treatment in nursing homes and hospitals? If these institutions are turning such a profit, why is there such a staffing shortage? Surely, they can afford to hire more staff, which is frequently stated to be a way to improve conditions in these settings. Hopefully, changes can be made soon, so that less people have to endure what Joseph Andrey did in his last months of life and more elderly people can die at home, if they so wish.

Solution to Problems with End of Life Care

In the article “Fighting to Honor a Father’s Last Wish,” the main problem that seems to drag Joseph Andrey from hospital to nursing home and back, not allowing him to be at home where he wanted, was the issue of money. His daughter did not have the resources or to take care of him at home; however, all the nursing homes wanted was to make money off of him. Medicare refused to give them money to be able to have him at home, and would only pay for his stay at a nursing home. This forced his daughter to do just that. Since nursing homes have become for profit, and insurance companies worry about nothing but the money they make, is there ever going to be a way that allows us to get the end of life care that we deserve? Making patients like a source of money truly dehumanizes all of us, yet these places where the elderly spend their last years of life are doing just that. Is it possible to have a balanced system where either for-profit nursing homes and insurance companies are both happy or the nursing homes become non-profit?

Heaven over Hospital

As people get older, especially once they have acquired illness, people who work in hospitals have a harder time believing that they should be resuscitated. In Timmermans article on social death, nurses mention that they believe the elderly have lived their life and sometimes resuscitating them causes them more pain than it is worth it.

There is also sometimes much debate on whether or not it is right to let a person die, even if they ask to, if not everything has been done to try to keep them alive. The opinion about this varies depending on the age of the person, and how sick they are.

In this article, it explains the story of a 5 year old girl with a fatal neurodegenerative disease, which causes her muscle and movement to get weaker and weaker. This means that as she gets older, it gets more difficult for her fight off sicknesses, even those as simple as the flu. As mucus began to develop in her lungs and cause pneumonia, she kept having to return to the hospital and undergo painful procedures to have it removed and also try to cure her every time she got sick.

Eventually the pain was so much that this 5 year old girl told her mom that next time she got sick, she would rather “go to heaven” at home rather than go back to the hospital and be treated again. This raises a lot of ethical questions. As a child who is only 5 years old, is she allowed to make the decision to not be treated? Since she is still able to communicate her wants, she should be able to voice her opinion; however, as parents this would be such a hard decision to make as they don’t want to see her in pain, but she is still so young and hasn’t experienced enough of her life. Do her parents have the right not to listen to her, especially since, in the end, it is her life?

I think that this is very similar to the arguments people give for abortion. In these arguments, they say that because a baby does not have a voice, a mother does not have the right to end his/her life. So now, this 5 year old girl does have a voice and opinion, are her parents still allowed not to listen to her?



Medicare’s funding of end-of-life discussions

In the New York times article “End of ‘Death Panels’ Myth Brings New End-of-Life Challenges,” author Paula Span discusses the debate over Medicare’s coverage of voluntary discussions with a physician about end-of-life treatment preference. When this idea was first brought to the table in 2009, conservatives claimed it was the precursor to government-sponsored euthanasia. This debate came to an end last month when Medicare authorized payment for end-of-life discussions. Doctors can now bill Medicare for discussion with their patients regarding end-of-life decisions. The first half hour of discussion is worth $86 and an additional $75 for 30 minutes more. Representative Earl Blumenauer, who first proposed the provision, states, “the apprehension and concern has slowly ebbed as public support got stronger.” This provision has gained a lot of public support recently. A public opinion survey directed by the Kaiser Family Foundation found that out of 1,200 adults polled, 80% feel that Medicare should cover doctor-patient discussions of end-of-life treatment. However, these conversations rarely take place. Span states “fewer than one in five respondents reported actually having had such a discussion with a health care provider, including only about a third of those over age 75 and about a third of those with a debilitating disability or chronic medical condition.” This is partly due to many patients not wanting to discuss end of life decisions with their doctor either because they do not know they can or do not feeling comfortable in doing so. Additionally, doctors should learn how to approach these conversations. Dr. Diane Meier, who leads the Center to Advance Palliative Care at Mount Sinai Hospital in New York, discusses how doctors are anxious about this and before doctors can start initiating these conversations, communication skills need to be practiced. Mr. Blumenauer intends to introduce legislation in 2016 to train health-care providers in end-of-life discussions and measure how well this provision is working overall. Although this provision may be difficult to get going, it has given health care providers incentive to start these important conversations with their patients.

Span’s article ties into several important issues that have addressed in class, including the manner in which a person wants to die and who should be making the decisions about care in an end-of life situation. Medicare’s authorization of payment for end of life discussions is beneficial for several reasons. First, this provision will encourage more patient involvement in end-of life decisions as well as encouraging doctors to initiate conversations with their patients about these decisions. As highlighted in class, patients or their families want to be the ultimate decision makers in end-of-life situations, but doctors tend to use their medical knowledge to sway patients or their families into making the decision they prefer. Having a discussion about end-of-life treatment with patients when the patient is fully cognitive and aware of their options could both decrease the decision-making authority of the physician and provide the patient with more control over their end-of-life decision. This provision will teach healthcare providers the importance of effective communication in the healthcare field, especially in end-of-life decisions. Only the patient can know definitely what decisions they want to be made in their end-in the way they decided as opposed to a one-sided decision made by their healthcare provider. Most Americans do not prefer to die in a hospital, but when the circumstances do not allow for an alternative, determining end of life treatment before it is too late will alleviate the patient and their family from additional stress and worry.


Should patients be released from ICUs to die at home?

    In class, we learned today about end of life care and the procedures that go into that care. Recently in the news, I’ve also learned that physician assisted suicide is becoming gradually more accepted, giving patients the right to end their pain. Although this is a large step from the indifferent end of life care and they do get to spend their last moments with their family, it is still in the hospital: a generally more morbid and depressive setting. The first thing we learned this lecture is how many patients and people in general would prefer to die at home. Shouldn’t we grant them that very right before they die?
    Instead of still having the patient hooked up until they decide they would like to die, maybe we should use tools such as fMRIs or EEGs to ask the patient if they would want to go home and live the end of their life there. By living the end of their life in the hospital setting, although they do decide to die, they end their life in the worst possible place, with sick and dying people around them. Releasing them from that setting, ultimately would grant them a little bit of happiness before they are let go with their family next to them. Death shouldn’t be as stigmatized as it is, and it only is this stigmatized because we related illness and hospitalization to death, when inevitable death should be looked as the moving on with life. It should be looked as spending time with family in a familiar setting when you move on instead of with grief and pain. So ultimately my question becomes should we release patients from hospitals and ICUs so they can die at home?

Right to Die?

In the past, death was accepted as nature and human interference rarely occurred. Today, hospitals in modernized countries have technologies with the ability to keep a person “alive.” This definition of alive could either be consciousness or simply preventing the bodily functions from turning down.

In class, we talked about problems with the aggressive treatment of terminal patients. At what point can a person say enough is enough to these treatments and just accept nature as is, without feeling guilt? I feel today in society, those who have access to technologies that can prevent their death and reject it is viewed as “dumb.”

Why even have advance directives?

In the Timmerman’s article “Social Death as Self-Fulfilling Prophesy,” he discusses, among other aspects of resuscitation efforts, advance directives: “advance directives, living wills, durable powers of attorney, and do-not-resuscitate orders” are all various legal methods to give a patient a say in what medical treatment they receive in the event of sudden death. If a patient does not wish to be resuscitated, they can make this clear through these advance directives, as they will be unable to do so if and when they do end up in this situation. Continue reading “Why even have advance directives?”