Obama’s Grandmother and End-of-Life Care Choices
Let me explain that another way. Dunham was told the surgery could kill her immediately. She was told that her end-stage cancer would cause cachexia, which is weight loss and wasting due to a disease process that causes the sick person to reject food and/or fluids, due to being sickened by them. (The difference between cachexia and starvation is that in cachexia, the person does not want food, can’t handle it, and rejects it. With starvation, the person wants food, can handle it, but does not get it.)
I don’t know why Dunham was told her quality of life would be terrible. Was it really attributed to being bed-bound from the hip fracture if she refused the hip replacement surgery or becoming cachectic due to the cancer, or both? Or something else like feeling lonely, abandoned, powerless, and frightened of the future?
Madelyn Dunham was offered the choice of surgery because our medical system still supports the autonomy of the individual to determine their own medical treatment, if they are able to do so. For end-of-life care, this includes the autonomy to decide whether to stay in the acute care system or enter hospice care.
In the acute care system, you continue to receive aggressive treatment to the end of life, regardless of side effects that may shorten your life or make life hard to endure, and when you die heroic measures are used to try to bring you back to life. (For example, CPR is a heroic measure. The EMT or nurse who performs CPR generally breaks the sternum and some ribs in the person receiving it — when the recipient is osteoporotic, all of the ribs may be broken. Survival rates after resuscitation are in the 1.4 to 5 percent range.)
In the hospice care system, your pain and anxiety are managed, appetite stimulants are given if needed, and you receive the food and fluids you enjoy and that your body can handle. The treatments and medications with side effects that you can’t stand and which no longer can save your life are withdrawn — ironically, this is the measure most likely to prolong your life and improve its quality. Also, in hospice care, you can die peacefully without the trauma of heroic measures.
Dunham may have seen her surgery choice as win-win: if she lived she could regain some of her walking and independence; if she died she escaped the slow death of cancer. Offering her surgery with such a small chance of success was not euthanasia because Dunham’s doctors all intended to save her life. It was not assisted suicide because Dunham probably intended to live.
However, Dunham was gambling with other people’s money against long odds for a small payout when the option to forgo surgery and enter hospice care had almost a 100 percent guarantee of longer and reasonably pleasant life.
Therefore Obama is right that we need to have a conversation among our medical experts and as a nation on whether to change the standard of care for the dying to have public monies pay only for hospice care.
In terms of conservative respect for individual liberty, Prof. Halper is wrong to force his values of requiring aggressive acute care for the dying on everyone because that violates the individual’s autonomy to choose between acute care or hospice care.
Personally, I hope we decide that we should pay whatever it takes to preserve the right of the dying to choose between acute care and hospice care, but bring costs down by improving the hospice care system and doing a much better job of explaining why and when to choose it. This satisfies the requirements of conservatism to protect individual liberty and to reduce the cost of government.
In the Netherlands, they are now at the “kill the patient even when he hasn’t asked to be killed” stage. In fact they are at the “‘kill the patient even when he (or his relatives since they aslo kill children) has asked not to be killed”. They call it euthanasia. I call it downright murder in order to save money to their socialized medicine system.
Thank you, JFM.. Similar to the message I originally had before my power went out a few minutes ago.. Healthcare rationing, euthanasia, murder/manslaughter, eugenics, you got it.
Lest an outage occur again, suffice it to (quickly) say that no rhetoric imaginable will cover the fact that our nation is consciously steamrolling towards:
Population Control, New World Order style..
The self-elected few have taken it upon themselves to now determine precisely whose Life is worthy of healthcare $$ expenditure of any kind and all others are to…….
Sit down, shut the [bleep] up, and graciously accept their Duty to Die.
Puh, yeah, good luck with that.
Warmest wishes from Talking Rock.
#1, you’re exagerating, does it help you for anything ?
according to this article, it is said that euthanasy is less and less used since the palliative cares are developped, that mostly a population above 80 still have this choice
http://www.lefigaro.fr/international/20070813.FIG000000199_en_hollande_les_soins_palliatifs_prennent_le_pas_sur_l_euthanasie.html
“In terms of conservative respect for individual liberty, Prof. Halper is wrong to force his values of requiring aggressive acute care for the dying on everyone because that violates the individual’s autonomy to choose between acute care or hospice care.”
It’s good to know that you support death with dignity, since that is fully covered under individual liberty.
Both my mother and several of my friends’ mothers (between 85 & 90 yrs.) passed away within a month of hip surgery to repair a fracture. Some had alzheimers, others did not. None had cancer or diabetes. I think the anesthesia for the elderly is often too much for them!
Been there, discussed this. Read “The Forever War” if you want to see what’s to come.
No my dear Marie Claude I am not. What the Dutch government does is look the other way when people who don’t want to die are murdered: ether the doctors aren’t prosecuted at all or when they are (rarely) they are sentenced to ridiculous sentences like suspended sentences of a few months in jail. You get more for killing a god (I remind you that the victims didn’t want to die).
I for one consider very dangerous the situtauion where the entity who is supposed to pursue, deter and, if at all possible, prevent crime has a financial interest in some people dying as soon as possible.
never heard of what you’re talking about for Holland, but for France, where a few cases occured, they all went in court, even if euthanasia was the justified patient’s desire
but you do have sources of course
“In terms of conservative respect for individual liberty, Prof. Halper is wrong to force his values of requiring aggressive acute care for the dying on everyone because that violates the individual’s autonomy to choose between acute care or hospice care.”
This sentence misrepresents my article. I do not advocate “requiring aggressive care for the dying.” I am arguing against denying care to people who are not dying or, rather, would not be dying if they received minimal care. Specifically, I claim that families are encouraged to allow demented patients to die when treatments are available because doctors believe that the lives of demented have no value. Doctors should not be making these judgments. To allow patients to be treated is not to require aggressive treatment. I am against heroic and futile treatments. Anyone who respects individual rights, as Yockey claims she does, ought to allow individuals to be treated even if they are demented.
Obama wanted to do everything possible to help his grandmother. His attitude is entirely laudable. As he realizes, his own health care proposals may make this impossible. I am hardly in a position to say what was best for his grandmother, nor am I advocating aggressive treatment for those in her position. I want to preserve her ability to choose treatment if she wishes. Obamacare may deny her this option.
Yockey writes as if there are just two options aggressive, futile care and hospice. In fact, there is much that is in-between–a whole range of normal medicine and nursing care. It is these in-between options that need to be improved. Why send patients who can be easily treated to hospices? Why rule out nursing care outside of hospices? Eliminate futile measures, leave hospice care for those who are dying, respect life and freedom–surely, most of us can agree on these points.
Finally, a note on hip replacements. My mother-in-law waited for surgery for a broken hip for five days in a Canadian hospital. After she finally got the surgery, she had to endure the attending physician’s announcing, by her bedside, that a woman of her age (80) with a hip replacement could not be expected to live more than a year. (Thankfully, two years later, she’s still kicking!) This is only one of many horror stories about the Canadian health system that many Americans would emulate. Once “quality of life” and “expected longevity” are used to determine care options, we face the prospect of limited care and, eventually, euthanasia.
The choice for Hospice or heroic measures is up to the patient and/or their family no matter what the state or age of the patient.
We are about to lose that right with socialized medicine.
5. Joanie:
Both my mother and several of my friends’ mothers (between 85 & 90 yrs.) passed away within a month of hip surgery to repair a fracture. Some had alzheimers, others did not. None had cancer or diabetes. I think the anesthesia for the elderly is often too much for them!
~~~~
What often happens with a hip fracture is the immobilization following surgery leaves the patient vulnerable to pnuemonia – and that is what kills.
Of course, I did read one Florida man who had to FORCE the hospital to treat his mother’s pnuemonia with antibiotics! Seems they were using her “advance directive” for no extraordinary means as an excuse to not do anything.
I’ve had these conversations with various of my own mother’s doctors. My mother was always quite liberal in not wanting ‘extreme measures’, then she learned that if you have that in an adanvced directive – they will do hardly *anything*, on the off chance an extreme case will lead to ‘extreme measures’. My liberal mother has revoked hers – she decided she DOES want treatment.
I wish people would not paint hospice as some wonderful answer to all of the dying process’ problems. Sometimes it’s a good thing, sometimes a very bad thing. Of my family, friends, and acquaintainces, it’s split 50-50. In my own experience with my father in hospice was a nightmare and I cannot imagine voluntarily using them again.
Let’s face it none of us are going to make it out of this world due to good health. We will all die of something somewhere in the future. Guaranteed. The question becomes one about quality of life. I personally don’t want to spend my last days in a hospital hooked up to tubes and machines. Life is not so precious, in my view, that we should spend an unlimited amount of resources to keep someone alive a week, a month or two longer. Death happens. It’s inevitable and you can’t stop it. Sorry to break the news.
My own mother fought emphysema for six months, then after spending a week in the hospital with them doing everything imaginable, she came home to die. A hospice nurse came out three times a week, gave my father a card with what to do when the time came, and she slowly faded away. She died in her own bed, my father there holding her hand as she went. The laws in Washington state are favorable to home hospice, but even then the card recommended waiting at list 20 minutes after any signs of life before calling 911, to avoid a nightmare scenario of ‘extremen measures’. Hospice isn’t for everyone, but some of us respect our life to much to spend the last few hours subsidizing the ‘death avoidance’ industry.
Solution to medical costs and insane treatments? Time to get medicine back into the marketplace. When is the last time a hospital ran a special on tonsillectomies? Or had coupons in your newspaper for carpul tunnel surgery? Get off your asses and tell your congresscritter to LEAVE MEDICINE ALONE!
I want to make it clear that I am opposed to euthanasia and assisted suicide.
Prof. Halper, you are so unfamiliar with the subject of end-of-life care that you are making up your own definitions of terms that are well-defined to people who do understand the subject. Your ignorance is so comprehensive that it makes it exasperating and exhausting to discuss the subject with you.
For example, you say:
“Yockey writes as if there are just two options aggressive, futile care and hospice. In fact, there is much that is in-between–a whole range of normal medicine and nursing care. It is these in-between options that need to be improved. Why send patients who can be easily treated to hospices? Why rule out nursing care outside of hospices? Eliminate futile measures, leave hospice care for those who are dying, respect life and freedom–surely, most of us can agree on these points.”
Hospice is a type of care, NOT a place. Hospice care can take place in a home, nursing home, assisted living — wherever the patient lives.
Hospice care is designed to provide both longer and better life to the dying and it delivers on that promise. Hospice care also allows you to refuse heroic measures and die peacefully.
I did NOT call acute care “futile care.” Acute care IS the “whole range of normal medicine and nursing care,” but at the end of life it is distinguished from hospice care by HOW you die — in acute care, they must perform heroic measures when your heart and/or breathing stops regardless of how slim the chances of reviving you are unless you have requested a “Do Not Resuscitate” (DNR) order AND your doctor has approved it.
Frankly, the “in-between options that need to be improved” that you are calling for mostly already exist but you are in a fog about how the health care system works and you do not know how to navigate it to find them. They are called “bridge programs” or “pre-hospice” and the main problems with them are that health insurance does not cover them, people don’t know about them and they are not available everywhere. In addition, for a number of reasons, people typically enter hospice care much too late to benefit fully from its measures that would prolong their lives. I think that needs to be improved.
It would be help this discussion if you would state the diagnosis that caused your father to be hospitalized. Was it aspiration pneumonia? Urinary tract infection and/or sepsis? Also, what is the name of the appetite stimulating drug he was prescribed? At least one is contraindicated for the elderly and is mostly used for people with AIDS, which would explain why it was not initially prescribed.
Also, as I recall, you described the bedside challenge of swallowing an ice chip, which your father failed, as a swallow study. It was not, but if a patient can’t swallow a small ice chip a complete swallow study is not done due to the likelihood that it would cause the patient to die of choking or aspiration pneumonia. I believe you were told that failing this test meant your father was dying of end-stage Alzheimer’s/dementia and that you and your family were asked what HE would want his end-of-life care to be — since, when you are acting as healthcare agents, your duty is to choose the care the patient would choose.
I want a healthcare system where your father, as a person with Alzheimer’s/dementia, has the choice between acute care and hospice care through his healthcare agents. I agree that you may be able to get your father several months more life, maybe a couple of years, with the care you have chosen for him, although he is likely to have a number of hospitalizations during that time for aspiration pneumonia, urinary tract infections and/or sepsis. I do not consider that futile care; it was wrong to say I did.
What I AM saying is that everyone comes to a point where their care choices cannot restore them to health, or maintain their lives, but instead only determine how they will die. The death you have chosen for your father is mostly likely to be suffocation from aspiration pneumonia or complications from having his sternum and all his ribs broken during CPR. To repeat, I support a healthcare system where your father has that choice.
Also, you were wrong in your article to characterize withdrawing food and fluids from someone who is both dying AND can no longer swallow as euthanasia. I wrote another article in addition to this one to explain why. PJM will decide whether or not to publish it based on readers’ reactions to this article.
The answer is simple; let people buy whatever health care they can afford with their own money. If they don’t have the money, don’t make others pay. If they have the money, let them buy as much medical care as their bodies can stand.
We have that system where elders can stay in their home. Some local associations provide them “services at home”, from twice a week to each day (depends on their means) to clean their home, make their purchases, ironing… meals. The cost also depends on their revenues (based on the Taxes office’s) health cares are also provided by nurses. Only if you need some heavy assistance like artificial respiration… you get to be transferred to Hospital. This system is very appreciated by the elders, also it costs less to the community than if these persons were in hospices or hospital. The Families are happy, cuz they have less obligations and worries. Until now, I haven’t heard anyone to complain about it.
Also it is creating employment, for women that are freed from breeding their offspring and without any particular qualification.
@16:
You really feel that we, as one of the most prosperous societies in the history of the world, have absolutely no obligation to ensure that every citizen receives at least some agreed upon standard of medical care, regardless of their socioeconomic status? I think that your viewpoint is incredibly selfish at best and incredibly barbaric at worst.
Patients and their families should have the right to purchase any ethical medical care a provider is willing to do for the patient. Cost is always a factor here both from the standpoint of family resources and cost-benefit.
What should we, through our government or through private charity, be willing to pay for? Certainly not every treatment that a patient who is not paying might choose to have, especially where there is an option.
Mrs. Dunham’s case is one where there is certainly a right to purchase treatment but where I, as a taxpayer, do not want to pay for that treatment as if it were a medical necessity.
What were the incentives of the physician that explained the options to Mrs. Dunham? I imagine that if she couldn’t afford the hip surgery and Medicare would not pay for it, the doctor would have been more encouraging about hospice.
Marie Claude
My sentence was uncomplete, should have read: “It is very dangerous situation when the entity in charge of prosecute crime, has a finacial interest in the death of cetain people and euthanasia is legal.
For now, it isn’t legal in France.
Don’t you find funny that the countries who have suddenly developped such concern about the sufferings of the terminally ill are, by a strange coincidence, countries who, like Spain where some “autonomical governements” are legislating to force hospitals to deliver “euthanasia”, who face a catastrophic demographic situation and will have appalling deficits in both retirement funds and social security?
JFM I don’t think that the people or “governments” that wanted or want to legislate about delivering “euthanasia” had/have these agendas, they rather want to fullfil a void in legislation, cuz “euthanasia” happen and it’s always a difficult dilemn for the families, the doctors and complications in trials.
Now Switzerland autorises “euthanasia” in private clinics too. I read that many ill French made a note by their lawer that they would recourse to it when they’ll judge they can no longer support their pain.
I myself am not against it if it is one’s own decision
I already said to my hubby, that if it happens one day that I cannot be autonomous, that I would prefer to choose this ultime mean too
#10 Ms. Attitude: “the choice for hospice or heroic measures is up to the patient and/or family…….” On that we agree. But I also recall the attempts several years ago by governmental entities and religious groups to intervene in the Terri Schiavo case. The fact that Ms. Schiavo had been determined by numerous doctors to be in a persistent vegetative state (PVS) didn’t seem to matter to those attempting to interfere in a family decision.
#15 Cynthia Yockey: “I want to make it clear that I am opposed to euthanasia and assisted suicide.” That’s fine for you; just make sure your legal documents are in order. But if a person is in severe pain with no hope of recovery from a terminal illness, you have no right to interfere in their personal decision to end things.
There is death. There is dignity. They do not go together.
#22 SteveB:
Regarding your comment, “But if a person is in severe pain with no hope of recovery from a terminal illness, you have no right to interfere in their personal decision to end things.”
Pain management is actually one of the main reasons that hospice care PROLONGS life WITH a good quality of life right to the end: hospice doctors know how to manage pain MUCH better than acute care doctors. Pain management for the dying is a specialty and in a completely different league than the pain management protocols in acute care.
The bottom line is that if your pain is not being controlled, you are not receiving appropriate care and it is improper care that is making you want to die, not the pain. And I am definitely going to interfere with people being forced into wanting euthanasia or assisted suicide due to improper care, especially since proper care is cheap and low-tech.
#23, Penny: Death and dignity do not go together in the acute care system as often as they should. But palliative medicine lifts every bit of pain and fear it is possible to remove from dying, which gives the dying and their loved ones the ability to express their love and say their good-byes. In those circumstances, there is great dignity and meaning available in the experience of dying.
This story is now on the front page of the Web site of the organization “Compassion and Choices,” which says it provides “information on self-determined dying when appropriate.”
There is NO SUCH THING AS APPROPRIATE SELF-DETERMINED DYING. If you think you need “self-determined dying,” it means you are NOT getting appropriate care!!!
On the Right we have people like Prof. Halper screaming “euthanasia” over care that usually prolongs and improves life and always respects it and is definitely NOT euthanasia or assisted suicide. On the Left we have actual euthanasia and assisted suicide cloaked in phony compassion by death junkies with God complexes, each and every one a minion of Dr. Kevorkian who, the Detroit Free Press reported in 1997, killed a number of people during his reign of terror who were not terminally ill and some WHO HAD NOTHING WRONG WITH THEIR HEALTH WHATSOEVER. The newspaper’s extensive analysis of Kevorkian’s victims is now available as a paperback book entitled, “The Suicide Machine.”
This is why I’m writing a book — to clear up misunderstandings and debunk the lies.
The problem with broken hips is that they usually lose blood flow to the seperated part and that can lead to infection and possibly gangrene of the hip fragment. This often leads to death, despite antibiotics. So what choice does the doctor have? You’re negligent if you do not “do something”.
to quote paul newman in the movie “Hud” none of are getting out of this life alive. life’s a bitch and then you….live! the only thing in life that really counts is not living or dying, but how many of the evil SOB’s you take with you when you go!
From a Catholic standpoint, it was allowed for her to refuse such extraordinary treatment.
Indeed, I’ve treated two patients in the US whose osteoporosis and other medical problems made surgery so risky we eleced to treat them medically, and they healed.
But I’m not sure that it would be cheaper: it would require six months of skilled nursing care.
The problem is that if the “mindset” of “euthanasia/price control gets embedded into the health care system, the alternative treatment, which requires a lot of nursing care and TLC, won’t be done either. The patients will merely be narcotized and food/fluids withheld until they die.
which is not the same thing as chosing non sugical treatment of a hip fracture.
Of course, there is a third alternative: Dump them home with the family.
We also had a relative here in the Philippies, also a non surgical candidate due to medical prolems, who died miserably of pneumonia three months after a hip fracture.
So I’m not sure that it’ cheaper in the long run, since skilled nursing homes are also expensive, and unlike the Philippines, one doubts that extended families would be available to treat these people at home.
#24 Cynthia Yockey “pain management is actually one of the reasons that hospice care prolongs life with a good quality of life right to the end.” I’ll beg to differ with you. I’ve watched family members in the last weeks of life. Even with good attempts at hospice type care, the pain wasn’t all managed and they WERE suffering. I think your generalizing on this sensitive topic does a disservice to those going through the process.
“the bottom line is that if your pain is not being controlled, you are not receiving appropriate care.” Sounds like a religious right argument to me and another generalized statement. You can’t impose your personal opinion on every medical situation.
“I am definitely going to interfere with people wanting euthanasia or assisted suicide due to improper care.” Gee, I just don’t know. Setting yourself up as some sort of god to impose your personal values on all other citizens seems pretty radical. Write your book if that is your desire. Deal with your own family. But stay out of other citizens’ personal & private lives.
“Also, you were wrong in your article to characterize withdrawing food and fluids from someone who is both dying AND can no longer swallow as euthanasia.”
You’re right. It’s not euthanasia.
It’s murder.
If someone did the same to an animal, they’d be thrown UNDER the jail.
EOD.
I, too, am shocked and alarmed by Obama’s attitude towards his own grandmother and the current proposal for cutting $600 billion from Medicare.
But those of you who think that we are “safe” under the current system don’t realize (or don’t care) that most of us who buy health insurance through our employers are denied payment for straightforward issues such as a broken elbow or a kidney stone. The for-profit health system is obligated – by law – to spend as little money as possible on health care so as to maximize profits for shareholders.
Also, my 88-year-old mother (who has 1 paying job and 2 part-time jobs) recently had stroke symptoms and went to the emergency room on a Saturday evening. The doctor showed up an hour or 2 later, asked her how old she was, and when she said 88, he snarled at her “How long do you want to live anyway,” and continued being verbally abusive for 2 or 3 minutes. Then he left, without running tests or providing stroke medication.
This is how Americans are treated right now. If you are too old, or too sick, to hold down an upper-middle-class job, and get any really serious illness … well, just prepare to die, you don’t have any other choice.
It looks like Obama will indeed make it even worse because his actions show that he thinks that health insurance and pharmaceutical profits are more important than people’s lives.
I had a chance to immigrate to Canada years ago, but felt it would be unpatriotic to do so. I lived there 3 years and although I was never ill, my husband was, as were other people we knew. Everything was free, fast, and competent. We assumed we were paying higher taxes. But when we returned to the U.S. and sat down and worked out the figures, we realized that taxes are higher in the U.S.
I’d take Canada’s system any day. Not that we’ll ever have that option.