Letter to Obama (If I was asked)

What I would say to President Obama if asked to render an opinion.

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“Ladies and Gentlemen, I have been involved in direct patient care for about 30 years. I’ve learned a lot, I’m still learning, and my experience is sufficient for me to give you some learned advice concerning the realities of how health care is provided, not the myths. I’m going to avail you of that experience for what you think it’s worth. When I get done doing that, Ill be taking care of patients again tomorrow and for the foreseeable future.

Ladies and gentlemen, in the past, those involved in about 80% of health care indemnification, Medicare and Medicaid, have tried to decrease the cost of heath care delivery by retroactively denying reimbursement for them after the services had been rendered. They have simply rationed by inconvenience, creating a default of “no payment” for I’s not dotted and T’s not crossed. You told voters they would be taken care of, then denied payment for a substantial portion of it. The reality is that encouraging unlimited demand in the face of limited supply is a recipe for disaster and that disaster is closing on us. You don’t need me to tell you where this is headed so I won’t insult you by re-hashing it.

Now I’m going to tell you where the cost savings are located and how to fix it. The money is spent, much of it squandered at end-of-life. The amount of money spent at the end of life, for which 80% of patients die in hospitals and specifically intensive care units, is staggering. It dwarfs money spent at the beginning of life, even for premature infants, most of whom go on to survive. All the other expenditures generally result in saving or salvaging life. Expenses at end-of-life prolong death and sometimes suffering.

Specifically, I’m talking about money spent to maintain patients with no potential to do any other than suffer, in areas designed for the resuscitation of salvageable humans. This is the area that you must eventually deal with. You might as well start thinking about it now. If you are not willing or able to effectively deal with resource allocation at this level, anything you try in other spheres will inevitably fail. And be sure, altering behavior in this sphere is fraught with political hazard for you because it will mean saying “no”, a word rarely used by politicians.

The root mean cause of this expense is twofold; that physicians are remiss in not exploring effective, compassionate and alternate end-of-life scenarios and that patient’s families have an incentive to maintain warm cadavers at taxpayer expense simply because they can. The result of this double whammy is a phenomenal amount of money spent to go nowhere. And let me be clear, there is only ONE way to alter resource allocation in this sphere of care and that is to change the mind set to palliation and make rules and enforce it, even in the face of “customer dissatisfaction”.

The point of indemnification is not to assure the heart’s desire of the consumer, it is to insure they will not be ruined financially for the rest of their lives following relatively moderate illness. There is nothing in any meaningful concept of indemnification that assures end-stage skilled nursing facility patients must be transferred to EDs or ICUs for disorders that will not improve their baseline function or do other than delay an inevitable death spiral. Similarly, there is no utility for anyone when CPR and the institution of life supporting measures such as mechanical ventilation or renal dialysis is instituted simply to prolong vital signs in an otherwise unsalvageable patient simply because it is desired, or the path of least resistance.

Patient’s and their families sometimes demand taxpayers underwrite these futile measures, sometimes indefinitely, because they can, because no one is willing to say “no” or “enough”. This will inevitably will stop anyway as we run out of money to finance it. It will be much more effective to control it prospectively before it crashes. There must be a paradigm shift in end-of-life consciousness for providers, which WE as physicians must institute. But in order to make it work, rules must applied that protect the potential survivors undergoing this kind of care, and cull out those gaming the system at taxpayer expense. And again, let me be clear, the break point is here and now, not in the future.

So it has come down to this. You must set the standard, and then take the heat from patients and their families desiring taxpayers maintain warm cadavers endlessly as equally a viable “right” as life saving procedures for a survivable patient population. If you are not willing to take the heat, then anything else you do will be ineffective. Period. There are a lot of knowledgeable physicians and providers out there willing and able to help you decide what rules will effectively get the job done, and how they can be enforced. If you choose not to recognize these realities, the real chances of physicians and providers actively aiding you to waste their time adjusting the unadjustable is pretty slim. Personally I would have no interest in helping you do that.

This is where it’s at, It must be dealt with effectively THIS YEAR. You cannot have it both ways. If it isn’t effectively dealt with, the viability of the entire health care provision system is in serious jeopardy.

Ladies and gentlemen, thank you for your time and for inviting me to give you my assessment of this problem.”

>COMMENT: First, as neurointensivists we
>are resuscitation specialists. Please tell me
>about the amazing case of someone with a
>terrible brain injury who you wrote off — and
>who recovered nonetheless — surely you have
>encountered this type of patient.

This is a common argument, especially among disabled Americans and Right To Life lobbyists. the fallacy is one of proportion.

If you make ANY decision at all about limiting life support for ANY reason, it is inevitable that sooner or later you will encounter a false negative. Someone predicted to inevitably die but unexpectedly survives. So there are those that say NO such decisions should EVER be made because of the potential, however small to be wrong. That means that career drug addicts should get as many mitral valves as they need for as long as they blow them because of the small but meaningful potential that they might someday decide to quit using IV drugs. Anyone with alcohol on their breath should get a liver transplant because they might decide to quit drinking. 92 year old patients with grade 5 subarachnoid, unresponsive on vents should get unlimited ICU care because they “might” survive.

It then simply becomes a question of how much you are prepared to spend to maintain how many moribund patients for how long to catch one unpredicted survivor. How much money do you want to take away from other cuts of the pie to support how many false negatives? Are you so concerned about the few outliers that you are willing to spend a virtually unlimited amount of money to string them up in multiple warehouses like in the film Coma”? Are you unwilling to make ANY decision regarding outcome because of the small potential you could be wrong?

If that’s the case, then you write Obama and tell him that the whole concept of conserving resource allocation misses the point. The point is that ONE patient falling through the crack out of a hundred, a thousand, a million is too many. We cannot possibly make any decision that might prove wrong, no matter how remote the possibility. We as a society should do ANYTHING to prevent a few from falling through the cracks, and that the taxpayers should rejoice at the opportunity of maintaining 1000 skilled nursing facility victims in ICUs indefinitely in the hope that one will wake up and go back to the nursing home to fight again another day.

>COMMENT: Second, I hear what you are saying
>about end-of-life care, but what specific actions
>can you recommend? I would say that the most
>important intervention is meaningful and intense
>discussion every day between the doctor and the
>family — I call it therapy. Rationing and limits on
>life and death will never work. I would not want
>to be part of that. Let’s make it the age of reason.

Families have figured out that they have an absolute right to demand anything they want. Mercifully, most of them don’t, but when they do, they don’t back down and we are obliged to provide it because there is no meaningful legal precedent to protect us if we refuse. We tell them” We wish you wouldn’t, but if you do, there’s nothing we can do about it so help yourself”. Calahan’s book a while back said there is only one way, that is to set objective limits on ages and number of organ systems failed for finite periods of time. Any subjective limits will instantly be challenged by lobbyists for interest groups and lawyers for individuals. If it’s a soft limit, those with a self interest will break it. It’s the American way. IOf you want to bring the cost of health care down from a GNP of 17%V to ~12%, this is what it will take. If you are willing to continue spending 17% and upwards with no end in sight, then continue on our current path and it will happen. is it worth it? You tell me.

What kind of limits? Negotiable. Limits low enough to protect patients amenable to resuscitation with some kind of quality of life, and strict enough to prevent admitting 90 year old nursing home victims with multi-infarct dementia (a PERMANENT disease).

>COMMENT: (XXXXX relates typical outlier
>predicted to die and survived intact): “I NEVER
>would have guessed she was going to make the
>full recovery that she made. She is back on the
>air in NYC”.

Like a previous comment extrapolating this issue to the death penalty, it must be remembered that no such thing as “guilty beyond ALL doubt”. By that standard no one would be convicted of anything. There is guilty beyond “reasonable” doubt, and if you accept that, and the justice system does, then the greater good is served. If you demand an absolute burden of proof, there is no point in ANY form of punishment. By doing so someone “might” fall between the cracks, so we should abandon punishment altogether and wait indefinitely for the absolute standard.

So I say again, does your story mean that you are unwilling to set ANY limits because of the potential for an outlier? I know doctors that do exactly that. The only acceptable cause of death is during the maximal application of everything possible. In that way no one could ever come back to them and say a patient “might” have survived if they had just done more.

Do you then advocate no limits, and if Obama tapped you to drive to Washington to advise him on what to do to make health care affordable for ALL Americans, would you tell him we cannot mess with the expense of maintaining thousands of warm cadavers because one or two of them might wake up? It’s a moral, not a legal issue and taxpayers will just have to live with it. Cut somewhere else. Maybe at the level of preventive medicine.

BTW, I can tell you the same story many times over and these patients have two factors that ought be plugged into the formula. They are young and they have no specific irreversible damage to their brain. Diffuse edema is potentially resolvable . This species of patient should be treated much differently than 81 year old nursing home victims with terminal multi infarct dementia and multi organ system failure. About every six months I get a hug from a 20’ish young woman that was literally on her way out the door for Donation after Cardiac Death when the nurse noted she began to show two fingers.

Your story is EXACTLY why we as physicians need to be involved in realistic rule making with bureaucrats.

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