The cost of trying to live forever

Why is this not an encouraging word? In a front page article, part of a Months to Live series,  New York Times writer Reed Abelson leads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die.  Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We could talk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.

Stress, sorrow and depression – – the dark side of the holidays

Win McNamee/Getty
Win McNamee/Getty

The photo on the front page of the Sunday New York Times tells the ultimate underside to holiday joy: a young woman, Sarah Walton, with her arms around the tombstone of her husband. The scene is in Arlington cemetery; the simple stone reads LTC James J. Walton and lists the parameters of his brief life, 1967-2008.

In households and hotel rooms everywhere, sadness and loss color the holidays gray. Most of the sadness is of a far lesser sort than that of the grieving widow, but just as real: relationships gone sour, bills that can’t be paid, health that can’t be restored — or the old, familiar pains of too many demands and too little time.

At my San Francisco church, a ‘Blue Christmas’ service was started four years ago by Associate Pastor Catherine Oliver, designed for those who struggle under the weight of everyone else’s festive spirits. Some of the faces she sees are familiar, but many belong to strangers seeking comfort or relief. This year, Oliver reports, attendance was not notably higher — “but there were more men.”

Acknowledging the stress and depression that so often accompany the Thanksgiving-to-New Year’s Day season, the Mayo Clinic recently posted a few tips to help bring a little peace and joy into the season. They are summarized here, in categories found to be common.

First, Mayo Clinic recommends, recognize holiday triggers so you can disarm them before meltdown occurs. Most common among these are:

Relationships. Relationships can cause turmoil, conflict or stress at any time, but tensions are often heightened during the holidays. Family misunderstandings and conflicts can intensify — especially if you’re thrust together for several days. On the other hand, facing the holidays without a loved one can be tough and leave you feeling lonely and sad.

Finances. With the added expenses of gifts, travel, food and entertainment, the holidays can put a strain on your budget — and your peace of mind. Not to mention that overspending now can mean financial worries for months to come.

Physical demands. Even die-hard holiday enthusiasts may find that the extra shopping and socializing can leave them wiped out. Being exhausted increases your stress, creating a vicious cycle. Exercise and sleep — good antidotes for stress and fatigue — may take a back seat to chores and errands. To top it off, burning the wick at both ends makes you more susceptible to colds and other unwelcome guests.

The good news is that even with the worst of causes, holiday blues can be lessened. Most effectively by following a few good recommendations such as these:

Acknowledge your feelings. If someone close to you has recently died or you can’t be with loved ones, realize that it’s normal to feel sadness and grief. It’s OK to take time to cry or express your feelings. You can’t force yourself to be happy just because it’s the holiday season.

Reach out. If you feel lonely or isolated, seek out community, religious or other social events. They can offer support and companionship. Volunteering your time to help others also is a good way to lift your spirits and broaden your friendships.

Be realistic. The holidays don’t have to be perfect or just like last year. As families change and grow, traditions and rituals often change as well. Choose a few to hold on to, and be open to creating new ones. For example, if your adult children can’t come to your house, find new ways to celebrate together, such as sharing pictures, emails or videotapes.

Set aside differences. Try to accept family members and friends as they are, even if they don’t live up to all your expectations. Set aside grievances until a more appropriate time for discussion. And be understanding if others get upset or distressed when something goes awry. Chances are they’re feeling the effects of holiday stress and depression too.

Stick to a budget. Before you go gift and food shopping, decide how much money you can afford to spend. Then stick to your budget. Don’t try to buy happiness with an avalanche of gifts. Try these alternatives: Donate to a charity in someone’s name, give homemade gifts or start a family gift exchange.

Plan ahead. Set aside specific days for shopping, baking, visiting friends and other activities. Plan your menus and then make your shopping list. That’ll help prevent last-minute scrambling to buy forgotten ingredients. And make sure to line up help for party prep and cleanup.

Learn to say no. Saying yes when you should say no can leave you feeling resentful and overwhelmed. Friends and colleagues will understand if you can’t participate in every project or activity. If it’s not possible to say no when your boss asks you to work overtime, try to remove something else from your agenda to make up for the lost time.

Don’t abandon healthy habits. Don’t let the holidays become a free-for-all. Overindulgence only adds to your stress and guilt. Have a healthy snack before holiday parties so that you don’t go overboard on sweets, cheese or drinks. Continue to get plenty of sleep and physical activity.

Take a breather. Make some time for yourself. Spending just 15 minutes alone, without distractions, may refresh you enough to handle everything you need to do. Take a walk at night and stargaze. Listen to soothing music. Find something that reduces stress by clearing your mind, slowing your breathing and restoring inner calm.

Seek professional help if you need it. Despite your best efforts, you may find yourself feeling persistently sad or anxious, plagued by physical complaints, unable to sleep, irritable and hopeless, and unable to face routine chores. If these feelings last for a while, talk to your doctor or a mental health professional.

None of the above can bring back a loved one, or make a new job appear. But perhaps they can help you through to a better and brighter New Year.

Stress, depression and the holidays: 10 tips for coping – MayoClinic.com.