Dealing With End Of Life

TW: Have posted on this several times. No doubt end of life is a challenging ethical dilemma. It is interesting that most discussion is framed on the elderly when in fact most of the same issues are relevant for everyone including premies, infants, children and middle-aged folks for that matter.

The challenge boils down to we have finite resources how do we manage them. When life and death is the topic such simplistic framing seems inadequate but without framing there is no basis upon which to address the challenge.

From Economist:
"IN RESPONSE to a post of mine from Friday, commenter MaverEcon made an insightful point: "Whenever people talk about death, it's all about platitudes. We're unwilling to have serious and respectful debates on the topic." The unseriousness is exemplified by those who toss around terms like "death panels" and "rationing" in an effort to close off debate on how end-of-life care should be managed. In reality, though, that is where the debate should begin.

In September, Lexington devoted his column to Americans' fear of death, noting

'Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean?'

For one thing, it means that Medicare spent $50 billion last year to care for patients in the last two months of their lives. As "60 Minutes" pointed out on Sunday, "that's more than the budget of the Department of Homeland Security or the Department of Education." It means we give liver transplants to the terminally ill, defibrillators to those with untreatable cancer. It means we use lots of money and resources, as if we have an endless supply of both, in order to briefly delay the reaper, or avoid looking him in the eye.

As a nation, perhaps that is how we want to spend our money. That's fine (if foolish). But we have so far reached that conclusion without having an honest debate over the benefits and costs. As others have pointed out, we condemn "rationing" as if we don't already do it. For example, instead of buying some of those defibrillators and paying for some of those transplants, we could computerise America's medical records. At this time, someone holding up a placard might accuse me of "killing grandma". In reality, though, my decision would save many more grandmas—a study found that between 2002 and 2004 nearly a quarter of Medicaid beneficiaries died due to safety incidents, many of which were likely preventable with better record keeping. But improving record keeping doesn't quite have the emotional appeal of caring for the elderly. So we give grandma her procedure, whatever it may be, while ignoring the fact that more money spent in one place means less money spent in another. Ignoring that every excessive procedure comes with a cost, in terms of the nation's overall health.

If nothing else, let's debate this (with Godwin's law in mind). I'm not arguing for a "Boomsday" scenario where we start enticing the elderly to end their lives early. But I do think we should become acquainted with the reaper before he comes for us. Not only will it allow us to have more honest discussions about how we use our limited resources (by the way, feel free to use your own money to pay for any care you want), but it will also lead to more dignified deaths. I know that sounds odd, but so does this statistic presented by "60 Minutes": "A vast majority of Americans say they want to die at home, but 75% die in a hospital or a nursing home." That is because we and our loved ones often do not consider death before it is upon us. That was the idea behind the so-called "death panels"—to make dying more dignified, not to bring it on more quickly. As a nation, we've so far dealt with that topic in a very immature way.

Any debate dealing with decisions about death will stir certain emotions. We should not ignore those feelings, but we should also not let them cloud our good judgment. There was a moving seen during the "60 Minutes" report where a doctor asked an elderly patient suffering from liver and kidney failure about one end-of-life scenario:

"Either way you decide, we will honor your choice, and that's the truth," [Dr Ira] Byock reassured [Charlie] Haggart. "Should we do CPR if your heart were to suddenly stop?"
"Yes," he replied.
"You'd be okay with being in the ICU again?" Byock asked.
"Yes," Haggart said.
"I know it's an awkward conversation," Byock said.
"It beats second place," Haggart joked, laughing.

The doctor thought Mr Haggart was condemning himself to a "bad death", suffering on machines with little to no chance of recovery. In this case, though, the goal wasn't to change Mr Haggart's decision. It was to make sure it was an informed one. But would it be wrong for me to point out that his ICU care would've cost up to $10,000 a day? That same money could pay for a year's worth of care for a person with type-2 diabetes. Let the debate begin."