Sunday, November 22, 2009

Dying in 14 Minutes of 60 Minutes


CBS did a segment entitled "The Cost Of Dying" on tonight's 60 Minutes.

Considering the title of the segment and the short amount of time alloted to it, CBS's coverage was accurate and thought provoking.

I'd have done some things differently.....for example:

Point made: Patients most often don't pay their medical bills out-of-pocket. In fact, they hardly look at their bill. My addendum: CBS should have provided actual price tags for costly EOL-in- ICU procedures, like CRRT, TPN, and mechanical ventilation, as well as data to show the percentage of time these procedures are in place but do not prolong life.

Point made: Most people want to die at home or in hospice, but instead die in hospitals. My addendum: Discuss the fact that patients have a choice; that a living will is easy to complete, does not require a lawyer/fees (in most states), and that patients have a right to make their own healthcare decisions, especially at EOL.

Point made: Technology is available to prolong life. My addendum: despite this technology, a terminal disease is just that - terminal - and patients have the right to determine how and where they want to die.

Point made: Hospitals are incented to admit patients, and doctors are paid by the number of patients they treat. My addendum: State that terminally ill patients have a right to limit their treatments and days in the hospital, especially at EOL. I want insurance providers and Medicare to require terminally ill patients to prepare for EOL as a condition of treatment reimbursement.

Point Made: Dorothy Glas, RN, stated that her mother saw many (read: 25) consultants in her final hospital stay before her death. She and the CBS interviewer Kroft agreed these were basically CYA consults. My addendum: CBS missed a good opportunity to (1.) discuss how malpractice litigation has a direct effect on skyrocketing healthcare costs, and (2.) ask Dorothy Glas RN why she didn't question the attending MD about the many consults. Did Ms. Glas have good reason to believe the consults were necessary, or had the patient herself stated she wanted 'everything done', hence all the specialists? Did the patient have a living will? I can't stop myself from thinking that the referenced psych consult might have been most appropriate, considering there were 24 others. My bet is the Palliative Care consult came last. Imagine the savings of money and complaints if PC had been consulted, say, within the first 6.

Point made: The $43,000 defibrillator implant in a 90-something year old. Dr. Byock referred to age and medical condition as reasons to question this procedure. My addendum: explore a patient's individual quality of life before we reference age. I've met a few robust 92 year olds that could run circles around a bunch of sedentary 72 year-old smokers. This was another missed opportunity; Geriatric Medicine would have fit very nicely here.

Point made: Dr. Fisher stated the reason patients are admitted to hospitals is because it's the "path of least resistance" since physicians don't have time to treat these patients in their offices. My addendum to that would be"why are we discussing this?". Yes, hospitals get 'direct admits' from the MD offices, but don't the majority of ICU patients come in through the ED? Then again, I'm no Dartmouth researcher. This was valuable time wasted on a curious finding.

It's unfortunate that Mr. Kroft asked Dr.Byock the So Yesterday question about pulling the plug on Granny. Dr. B did a decent job of defending himself, albeit in a brusque sort of way. His intensity on camera is probably balanced by an endearing, sincere bedside manner. Too bad CBS didn't interview one of the many patients who are undoubtably grateful for his interventions. I admire his passion.

I'm grateful to the CBS Fates for not airing the words 'Palliative Care' without a full explanation.....and there’s no telling what that explanation might have been ……phew...

Check out the CBS 60 Minutes website for additional segment info, videos and comments.


Posted by: Barbara Brown, RN CHPN

5 comments:

ken covinsky said...

Thanks DL for a wonderful overview of the piece. Hopefully many of the issues you raised will get attention in follow-up discussions.

Overall, I thought the 60 minutes piece was outstanding. Yes, if I had the opportunity to produce the piece, I would have done some things differently. But, I found the presentation thoughtful and respectful of the intelligence of the audience. It showed respect for the complexity of the issues and unlike many other media presentations, avoided simplistic, emotionally charged, but baseless rhetoric. Kudos to Mr. Kroft.

Dr. Byock did an outstanding job. He confronted the difficult question of costs head on, but did it in the context of a great doctor who cares deeply about his patients.

If I had been the producer of the piece, there is one thing I would have done differently. I would have changed focus from the costs of care to human suffering. The central problem with much of the care provided at the end of life is that it causes great suffering to patients and families. In most cases, this care does nothing to prolong life, and may even shorten life. The piece focused on patients who "want everything" but it is worth mentioning that often patients and families want "everything" because the quality of communication has been poor, and they don't understand the that what they perceive as "everything" may cause suffering and will be ineffective at prolonging life. Sadly, many don't realize that one of the options under "everything" is aggressive care focused on the patient's quality of life. The main reason for us as a society rethinking the care we provide at the end of life is the toll of our current practices in terms of suffering. That this care also costs a lot of money just happens to be the final insult.

I actually loved Dr. Byock's answer to the "pulling the plug on granny" question. In particular, I loved his response that in his daily work, he affirms life. I think our disciplines could do better if we talked more about life. This is not about "denying reality." It is being explicit that care focused on relief of suffering, grounded in the unique needs of each individual, and that recognizes that the quality of life of patients with very serious illness is an imperative IS life affirming.

There is an excellent commentary on the 60 minutes piece at Pallimed

Patrice Villars said...

Great post.. made me go back to my DVR and look at the piece. While I agree with Ken that it would be been better (for us) to focus on human suffering, I think an opening for general discussion about EOL care is through our (U.S.)fears around costs. The tension lies among our fear of mortality, our fears of 'wasteful government’ spending and our fears of loss of personal choice. (Remember, we who read this blog are not the general U.S. voting population.) Sadly, with our political climate as it is, perhaps this is the best way in (for now)to get the message out that there just might be a different way to approach advanced illness and dying.

Christian Sinclair, MD said...

Excellent point Ken about the what should have probably been the real focus for the piece. From addressing suffering we could probably get to a much more rational discussion about costs instead of the other way around. A wag the dog situation I guess.

It also is a good reminder to note that good palliative care does not necessarily come cheap either.

For interconnectedness sake, I also blogged about the 60 Minutes piece at Pallimed.

Anonymous said...

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Chicago Bridge said...

I enjoyed your post and linked to it in my post through the Chicago Bridge

http://www.thechicagobridge.org/hospice-the-business-of-dying/