Not long ago I attended an event at San Francisco’s Commonwealth Club, featuring a speech by the President’s Council of Economic Advisors Chair Christina Romer. Dr. Romer’s talk, “The Great Credit Freeze and the U.S. Economy,” was all about improving healthcare while slowing down the growth of its cost. We know we can’t reduce costs, she said; what we hope to do is reduce the rate of increase. And one way to contain healthcare costs might be to find out what the patient wants. Imagine.
This observation was not in direct response to a question, but could well have been. Dr. Romer was asked, by more than one audience member, about how to address excessive expenditures at the beginning and end of life. A grossly disproportionate share of costs, she conceded, “are spent on the last six months of life. And one thing we’re not doing enough of is letting patients express what they want.”
If the issue were not so grim and sorrowful it would call for a “Well, duh.”
It would be hard to find many people saying they’d like their last few days on this planet to be spent semi-conscious or in pain and distress, hooked up to a tangle of wires and tubes in a blue-lit hospital room (see Scott Bowen’s post 7/14.) But this is in fact the system we have created: we focus on prolongation of life without regard to quality, we aid and abet doctors who equate death with failure, we never talk about our own mortality as if in silence we can become immortal. Most of us would choose to die at home, properly medicated for pain and surrounded by our loved ones; most of us will die in an institution
Audience members had a wide assortment of questions, and Dr. Romer had plenty more to say. But finding out what the patient wants, and acting accordingly, is surely one excellent path towards better care – and even contained cost growth — and everyone in America could begin that process today.
It is an easy solution, even if only a small, partial solution, to this piece of the muddled medi-puzzle of our healthcare system: talk. Tell your doctors, caregivers, loved ones what you do or don’t want. Write it down. Use the forms universally available (Advance Directives, POLST, others.) You might even wind up with what you actually want in your final days. Christina Romer is on your side.
Bracelets are good. I sometimes consider having AND (for Allow Natural Death) tattooed on my chest; AND seems so much more calm and reasoned than DNR. But you’re right. I hope POLST forms will at least be of help, even in some ER situations.
You might also consider having your wishes (if they’re straightforward, like DNR/DNI) printed on a medic alert bracelet. I can’t tell you how many times we see patients brought into the ER after they’ve collapsed in a public area or were found down in their apartment, they’re resuscitated with a significantly impaired outcome, and then the family arrives and says “She never would have wanted CPR”. The knee jerk in the ER is to perform CPR unless the family member or paperwork instructing the physician to do otherwise is right there, which doesn’t happen as often as you’d think.
Fran Johns is the consummate writer — concise, explicit, witty and compassionate. Her work with end-of-life choices is well-known, and she writes about this issue with great knowledge, but especially, with plenty of heart and her delightful brand of dry humor. She’s a joy to read and True Slant is lucky to have her.