October 24, 2009
More Americans Than Brits Die In Intensive Care Units
When Americans are near the end of life hospitals try to keep them alive past the point their bodies can do it. Does anyone think this is a good idea?
Patients who die in the hospital in the United States are almost five times as likely to have spent part of their last hospital stay in the ICU than patients in England. What's more, over the age of 85, ICU usage among terminal patients is eight times higher in the U.S. than in England, according to new research from Columbia University that compared the two countries' use of intensive care services during final hospitalizations.
"Evaluating the use of intensive care services is particularly important because it is costly, resource intensive, and often traumatic for patients and families, especially for those at the end of life" said Hannah Wunsch, M.D., M.Sc., assistant professor of anesthesiology and critical care medicine, of Columbia University, lead author of the study. "We found far greater use of intensive care services in the United States during terminal hospitalizations, especially among medical patients and the elderly."
I support the use of ICU equipment when someone has suffered a severe trauma or even a heart attack where they have some prospect of recovery. But if you are going to die then what's the point?
Suppose ICU technology keeps advancing and people can be kept alive on machines while, say, cancer ravages their brains, bones, etc. Isn't it torture to keep people alive under those circumstances? I've been close enough to someone who was dying that I've sat across from a hospice nurse who explained to me such things as, for example, if the person had a heart attack then attempts to revive would likely break ribs (the ribs were full of cancer) and that this would just make them live longer with even more pain. There was a conscious decision by all concerned to avoid the hospital. I wonder how many people get taken to the hospital to die in an ICU after a few extra horrible weeks of life because there's no family members available to talk it out with doctors and hospice people in advance.
I wonder how many people get taken to the hospital to die in an ICU after a few extra horrible weeks of life because there's no family members available to talk it out with doctors and hospice people in advance.
I saw a NYT article recently that said this kind of thing was pretty common for dementia patients. Very sad.
I'm a nurse working with such patients in a hospital forced to provide a great deal of "free" care. Most hopeless cases of people forced to stay alive on machines are there due to family members who refuse to let them go. The reasoning of many of these family members is there is always hope. Most have watched way too much television where someone comes out of a coma after twenty years and lives happily ever after. Also a fairly high percentage of family members are gaining financially while their sick relative remains alive by living rent free in their home, cashing their pension checks, etc.
My solution is to make the family member with decision power responsible for a nominal daily co-pay. Even a charge of as little as $20/day would soon make the miracle believing family member soon appreciate it was time to let their sick relative go.
It is situations like this that make me oppose any public health plan which provides unlimited "free" medical care. Unless a person or the person/people responsible for them pays something any medical system will be abused. For family members unable to provide $20/day I'd hand them a broom and have them start sweeping the hospital.
I wonder how many end of life ICU experiences actually result in end of life. Evaluating what constitutes end of life medical conditions is still very much an art. Two weeks ago, a friend's grandmother was sent home with pain meds to die. Doctors said it was imminent. They didn't understand what was going on, but could see the clear trend lines in her progress. She started recovering within 2 days of getting home, and is now ambulatory and engaged in life.
So I wonder how many end of life evaluations in the UK cause end of life. Based on recovery rates from different kinds of diseases/cancers between the UK and the US, IIRC, it appears that the American can-do attitude enables us to do, while fatalism i such cases will typically prove prophetic. That said, hospice care is a wonderful thing, imported into the US in the last few decades.
I agree the House mentality where there is always hope and brilliant doctors can save just about anyone wastes unnecessary resources. I pity us if we choose the other path.
Americans are more likely to die in ICU because the Brits die before getting there.
I concur with Barbara E. I am a retired physician. During my Internal Medicine residency I experienced the same phenomenon she describes. I would frequently discuss a demented patient's care with their family, sometimes regarding a possible transfer to the ICU. If there was no financial incentive involved, the family members would usually just ask me my opinion about what to do. If there was a pension check involved, they would always tell me to "do everything possible." In the latter case, if the patient died anyway, there would be rumblings about a lawsuit.
The real answer is that you really want the technology to exist. There are plenty of situations where lives are saved, that would otherwise be lost. The British solution is not a humane or just solution. They are simply killing people (go read the article Bruce linked above) in order to save money.
Fortunately, you can solve this problem for yourself and your family. It takes three steps. First, you need to figure out things for yourself.
Second you need to get your family on board. Nothing will screw things up at the hospital faster than having a bunch of hysterical family members trying to undermine the decisions made by you or other family members.
Third, you need formalize the decision. Most states have forms for "living wills" (a/k/a advance health care directives) forms that set out what you want, and health care proxies (a/k/a health care powers of attorney), forms that designate another person to make decisions for you if you cannot communicate. Talk to your lawyer or doctor about the forms, and local requirements as to signatures, witnesses, and notarization.
Here are some links to web resources on these issues:
Aging with Dignity is a non-profit organization, which wants to protect the human dignity of the aged and to promote better care for those near the end of life.
Caring Connections, a program of the National Hospice and Palliative Care Organization, supported by a grant from The Robert Wood Johnson Foundation.
Remember, only you can prevent forest fires.
How about offering every senior citizen eligible for medicare or medicaid $5000 to sign a strict living will?
>If there was a pension check involved, they would always tell me to "do everything possible."
Fortunately these sorts of pensions (defined benefit) are becoming extremely rare for new workers, especially in the private sector, and the old ones are also disappearing because some of the plan sponsors are going bankrupt (Delphi's plan went bankrupt).
I like the UK's system of having a basic public medical care for free, and those that want the luxury of world-class care are free to pay for it themselves.
Average lifetime income + benefits for Americans is what, $2 million? In a free market I don't think many people would voluntarily spend a quarter of their total lifetime income on heroic end of life care to live an extra year. If that's the case, the public shouldn't pay either.
From what I understand, it's incredibly difficult to get medical care and assistance for seniors in Britain. After watching a parent suffer to death for years, I think it might be a kinder way to treat our elderly. Either that or we implement "Hurling Day" ( http://www.imdb.com/title/tt0760613/ ).
According to Aubrey de grey we are very close to ending aging (http://www.bigthink.com), so in the future we can choose when to die.