Respectful Insolence

American medical care at its finest

What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases? Palliative care? Hospice? Those would seem to be the most reasonable options. If I were that 90 year old man, that’s what I’d recommend. Unfortunately, I know from experience that that is all too often not what happens. I know and have seen the ordering of many invasive tests that won’t change the outcome.

So does Buckeye Surgeon.

American medicine, as it is practiced now, all too often takes on a momentum that is very difficult to stop, a momentum demanding more, more, more, more, even in the face of a hopeless situation. Sometimes it’s driven by the family’s desire that doctors do “everything possible,” but, as this case demonstrates, it can happen even without such an insistence. It seems to happen even though individual physicians involved know there’s no hope and that what they’re doing is futile. It is a major contributor to the way that end-of-life care makes up such a large portion of what we spend on healthcare.

Comments

  1. #1 Dianne
    June 13, 2009

    For a 90 year old with an ECOG PS of 0-1, no uncontrolled co-morbid conditions, AND a desire to try aggressive treatment I might suggest a clinical trial, if an appropriate trial were available or some tolerable chemotherapy like single agent gemcitabine that might improve symptoms without causing too much in the way of side effects. Otherwise, hospice is really the reasonable option.

  2. #2 Reality Rounds
    June 13, 2009

    This story reminds me of when they wanted to do a cardiac cath for my grammie who was having mild chest pain, and shortness of breath on exertion. She was 91 at the time. Her primary doc ordered the test. We all said NO way, and thankfully, so did the cardiologist. Grammie died at 97,peacefully, in her own home.

  3. #3 bigjohn756
    June 13, 2009

    How about a self administered injection followed by a nice, long, very long, peaceful sleep. Unfortunately, that choice is not generally available to the gentleman.

  4. #4 GeekGoddess
    June 13, 2009

    I did not keep the article, so take this as you may, but a study that I read about reported that ‘last-ditch, do-everything’ actions were more often pursued by the religious than by secular/atheist people.

  5. #5 Nils Ross
    June 13, 2009

    #4, I read the same article. I didn’t look into confirming the data. It makes intuitive sense to me, but then, it would: I’m a secularist. Death is the last great adventure; it would be a shame to fall into it in from some kind of drug-hazed machine-supported semi-conscious existence.

  6. #6 Alan Kellogg
    June 13, 2009

    Here is my proposal; we boobytrap the very old. Any physician attempting an invasive procedure on such a patient pays the (possibly fatal) consequences of his actions.

  7. #7 Scott Everson, RN
    June 13, 2009

    how about a prophylactic whipple with wedge resects and ablation to smaller mets? some ahole surgeon would do it. And kids in THIS country STILL don’t have health insurance?

  8. #8 J. Shryock
    June 13, 2009

    My 90-year-old mother had been in a locked Alzheimer’s facility for four years and was to the point that she could no longer even talk. She became ill, and the facility sent her to the hospital. The doctor called me and said on x- ray she had a large small-bowel obstruction, and they were scheduling surgery!!! I said I have power of attorney over my mom, and there will be nothing done except comfort care until she passes away. I went straight to the hospital with my power-of-attorney document to reiterate my wishes. The young surgeon actually wanted to argue with me about why my mom should have surgery. She didn’t and was gone from this world in less than 6 hours. The correct choice and outcome were achieved no thanks to the doctor in charge. What’s the matter with these doctors?

  9. #9 J. Shryock
    June 13, 2009

    My 90-year-old mother had been in a locked Alzheimer’s facility for four years and was to the point that she could no longer even talk. She became ill, and the facility sent her to the hospital. The doctor called me and said on x- ray she had a large small-bowel obstruction, and they were scheduling surgery!!! I said I have power of attorney over my mom, and there will be nothing done except comfort care until she passes away. I went straight to the hospital with my power-of-attorney document to reiterate my wishes. The young surgeon actually wanted to argue with me about why my mom should have surgery. She didn’t and was gone from this world in less than 6 hours. The correct choice and outcome were achieved no thanks to the doctor in charge. What’s the matter with these doctors?

  10. #10 J.Shryock
    June 13, 2009

    My 90-year-old mother had been in a locked Alzheimer’s facility for four years and was to the point that she could no longer even talk. She became ill, and the facility sent her to the hospital. The doctor called me and said on x- ray she had a large small-bowel obstruction, and they were scheduling surgery!!! I said I have power of attorney over my mom, and there will be nothing done except comfort care until she passes away. I went straight to the hospital with my power-of-attorney document to reiterate my wishes. The young surgeon actually wanted to argue with me about why my mom should have surgery. She didn’t and was gone from this world in less than 6 hours. The correct choice and outcome were achieved no thanks to the doctor in charge. What’s the matter with these doctors?

  11. #11 natural cynic
    June 13, 2009

    American medicine, as it is practiced now, all too often takes on a momentum that is very difficult to stop, a momentum demanding more, more, more, more, even in the face of a hopeless situation … It is a major contributor to the way that end-of-life care makes up such a large portion of what we spend on healthcare.

    You really don’t understand medical economics, Orac. The esteemed epidemiologist, economist, political theorist and fatassed blowhard, Rush Limbaugh tells us who is really to blame for high medical costs. People who exercise and get injured.

  12. #12 Donna B.
    June 13, 2009

    #4, #5 – I’d love to read that article, if you can point me to it. I’m an atheist, but most of my (quite large) extended family is very religious. Several are preachers. And that has not been my experience in dealing with the elderly, but it is much more likely to happen when it’s a younger person.

    I can’t speak highly enough of hospice care, but hospice care at home is not for every family. It’s a helluva lot of work and the caregiver must generally be in pretty good health with a decent amount of physical strength.

    My step-mother got hospice care at home for a little over three months before she died. Lots of prayers were offered for her, but none (that I heard) were for extending her life, they were all for an easing of the incredible pain she was in. It was always acknowledged that death would end the pain and no one wanted her to suffer.

    After seeing what she went through, I sort of hope I do get hit by a bus. But not until I’m 99.

  13. #13 Mary
    June 13, 2009
  14. #14 Rowan
    June 13, 2009

    A number of years ago my great aunt, a staunch Roman Catholic, was diagnosed with esophageal cancer at the age of 88 years. The doctors wanted to perform surgery and chemo. She was told to expect a two year stay in a nursing facility for recovery.

    She told the doctors thank you for their concern however she thought they were crazy for considering such procedures for an old woman. She asked to be sent home with morphine to control the pain.

    She had home care with pain management for approximately a year before she passed away in her own bed.

  15. #15 Jacob Wintersmith
    June 13, 2009

    This sort of story makes me wonder why cryonics isn’t more popular than it is. The odds of being defrosted and returned to health in the future may not be very high, but they’re better than zero. Seeing what the doctors proposed for that patient, I’d say that having yourself frozen is substantially less crazy than many other desperate (and expensive) attempts to preserve life against all odds.

  16. #16 sikiş
    June 13, 2009

    Personally, I think cats make the best sort of therapy pet for someone on the spectrum, and a mildly tongue-in-cheek book entitled “All Cats Have Asperger Syndrome” probably agrees with me (I think it was meant to introduce children to the concepts of Asperger’s, actually, but it reads like proto-lolcat).

  17. #17 Dianne
    June 13, 2009

    Let’s not get carried away in the other direction. Just because someone’s old doesn’t mean that they’re ready to drop dead and no medical care is going to be useful. My great aunt suffered early CHF related to aortic valve stenosis at 88, underwent valve replacement surgery, and is still alive and apparently healthy 6 years later. The average life expectancy with AoVS and CHF without surgery is something like 6 months. Aggressive treatment can be appropriate at any age. Conversely, all treatment for metastatic pancreatic cancer is palliative. It’s not a curable illness at any age.

  18. #18 Donna B.
    June 13, 2009

    #13 – Thanks for the article link. That study prompts a lot of questions, but in relation to the current post, this paragraph caught my eye:

    “Patients who reported a high level of positive religious coping were more likely to be black or Hispanic. They also tended to be less educated, were less likely to have medical insurance, or be married than patients who reported a low reliance on religion.”

    The part about less educated and less likely to be married are really interesting. Less educated could translate into not knowing what questions to ask or even thinking the tests were some kind of treatment.

    Not being married could mean fewer relatives, especially younger relatives, around to ask questions.

    I’m wondering if these patients a)requested the treatment they got, b) if the treatment legally had to be done for them if they didn’t plan ahead and have their wishes written down beforehand, and c) finally, if the treatment was done because it would be paid for.

    I understand that c doesn’t quite equate with the not likely to have insurance part, but I would have to see the numbers to find out the ages. It seems likely that most advanced cancer patients are old enough to be on medicare, or possibly poor enough to be on medicaid.

    #17 – age alone does not determine how near to the end of life one is. My father is 86 and was recently diagnosed with Stage 1 NSCLC. It was found accidentally and causing no symptoms.

    He’s chosen radiation treatment because he thought that gave him the best chance for an active life for a longer period. He’s in otherwise good health and feared the recovery from surgery or chemotherapy would rob him of good time now.

  19. #19 khan
    June 13, 2009

    Is a euthanasia option available for old and suffering folks?

    Or maybe a hospice and starve to death with pain killer option available?

    Or is there some reason people have to suffer pain and disability for years against their will?

  20. #20 DLC
    June 13, 2009

    But what did the 90 year old patient want ?
    Sure, I know, academically, that his disease was not something one usually recovers from. And at his age, the odds of his tolerating chemo and surgery (even though it wouldn’t ‘cure’ his cancer in this case) would be small, most people don’t want to die. Hell, I don’t want to die either.
    So, given that, most people would probably accept the idea of more (or even invasive) tests, hoping the whole time to wake up and find out they’ve been cured or there was actually a mistake and they’re not going to die after all. It doesn’t always make sense, but humanity does not always make sense.

  21. #21 bob koepp
    June 13, 2009

    Finally! DLC has raised the question that needs to be asked _first_. It’s not that I disagree with the various alterntives that posters have mentioned, but I wouldn’t dream of suggesting consideration of, much less recommending, any of them until I had some sense of what the patient might prefer in this situation.

  22. #22 Chris
    June 14, 2009

    DLC:

    But what did the 90 year old patient want ?

    and

    bob koepp:

    DLC has raised the question that needs to be asked _first_….I had some sense of what the patient might prefer in this situation.

    You need to read the linked article by the Buckeye Surgeon. He basically canceled a bunch of invasive and possibly painful tests, called the son in Alabama and wrote on the chart encouragement for a hospice consult, a chance to discuss the options. The last paragraph gives the outcome:

    The next day, the dogs were called off. The son arrived from Alabama. They had decided to forego any further treatment. He would take his Dad home….

  23. #23 Mark p
    June 14, 2009

    “But what did the 90 year old patient want ?”

    And what about the people who suffer or die because money was wasted on this man?

    Even if he was on insurance, that doesn’t stop someone else suffering. Needless costs due to needless procedures push up the premiums. More careful use of money would mean more people could get coverage, because premiums would be far less.

    This attitude of “give every possible treatment” is why the US pays more than any other country on medical treatment, yet gets worse treatment. Far too much of that money is wasted.

  24. #24 Donna B.
    June 14, 2009

    Mark P – I think you have misunderstood the question… primarily that the question was not asked of this 90 year old man.

  25. #25 Chris
    June 14, 2009

    Donna B., Mark p is another example of someone who did not read the link to the Buckeye Surgeon’s blog posting.

  26. #26 Lassi Hippeläinen
    June 14, 2009

    “What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases?”

    A bottle of whiskey, every day.

  27. #27 DLC
    June 14, 2009

    I read it, and it still doesn’t say if the old man actually agreed to or asked for the day-long series of tests. It only says they were done. There’s nothing there either way about if the old guy asked for a second opinion or not, or if he wanted more tests or not, but there’s a goodly amount of assumption that he should have taken Buckeye’s word for it and made his final arrangements. Now, don’t get me wrong, Buckeye was no doubt right in suggesting hospice care.
    Now me, if you come to me and tell me that there’s nothing you can do and why don’t I go and call whosis over at the hospice and they can make me comfortable until “The End”, I’m going to tell you to go to hell and demand a second opinion. And maybe even some tests that you don’t agree to.
    So, based on my own likely reaction to being told I’m terminally ill, I had to wonder what 90 year old man’s was.

  28. #28 DLC
    June 14, 2009

    Oddly, I am reminded of the article I read about the Texas department of corrections “death row” practice of granting the condemned his choice of last meal, unless it’s too weird or “bad for you”. Yeah, you heard right. you don’t get the last meal of your choice if it might contribute to heart disease.

  29. #29 Jen
    June 14, 2009

    “This attitude of “give every possible treatment” is why the US pays more than any other country on medical treatment, yet gets worse treatment”

    I’m reminded of the Fat Man’s law #13: “The delivery of good medical care is to do as much nothing as possible.”

    “The House of God” should be required reading for everyone working in health care.

  30. #30 Dianne
    June 14, 2009

    This attitude of “give every possible treatment” is why the US pays more than any other country on medical treatment, yet gets worse treatment.

    I don’t know the literature on what the costs of the US-American versus other medical systems are, but this statement sounds highly debatable to me. There are a number of other excess costs associated with the US medical system. US-Americans, especially the un- and underinsured use ERs more than people in other first world countries. ERs are great if you’ve just been hit by a truck but lousy places to get your chronic care. US-Americans may also present later in the course of their illnesses due to lack of insurance, lack of sick leave, or pressure to not take sick leave that is ostensibly available. Late stage disease is harder to treat and more expensive. I don’t know what the relative contribution of these factors to the cost of health care in the US is–does anyone know if the data exists?–but there are at least several other problems that could be solved in US healthcare before we have to talk about rationing. And it is rationing you’re talking about, even if it is under the guise of not overtreating.

  31. #31 Patient
    June 14, 2009

    “But what did the 90 year old patient want ?”

    With the daughter having power of attorney to approve/disprove medical decisions, one would have to assume that the 90 year old patient was not in a condition to make that decision for himself.

    My 88 year old father is in the middle stages of Alzheimers and can’t decide what he wants for breakfast or if he even wants breakfast, let alone decide on life extending medical care. Unfortunately he indicated on a medical directive prepared a few years ago, that he wants everything done to keep him alive no matter what the cost. At the time he signed it, I argued with him that seeing as how painful it was to watch his own father die from Alzheimers, why would he want to be kept alive for years on tubes, and possibly in pain, with no memory of his children or what was going on?

    He said that just because his father had a problem doesn’t mean that he will, and by that time science will figure out a way for us all to live to 100. That was his goal, to get to 100 at any cost, and it will sure be at any cost–to society, to his own personal pain and suffering, and to his children that have to watch all this, powerless to do anything about it because he signed that piece of paper.

  32. #32 ck
    June 14, 2009

    Two things:
    1. Making a tissue diagnosis in this case is mandatory, then consult hospice if adeno.
    2. Lawyers have substantially contributed to CYA medicine.

  33. #33 Chris
    June 14, 2009

    Patient:

    With the daughter having power of attorney to approve/disprove medical decisions, one would have to assume that the 90 year old patient was not in a condition to make that decision for himself.

    What daughter? From the Buckeye Surgeon:

    He lived alone in an assisted living facility. He had a son in Alabama, but that was it.

  34. #34 Dan Hocson
    June 14, 2009

    As a medical student, I helped care for a man with advanced hepatic cancer. Once he was aware of the diagnosis and prognosis, he made it very clear that he wanted no surgery, chemo or other aggressive treatment.

    The oncology team, though, would not let up. They constantly badgered him with requests to attempt various treatments. It got so bad, that the poor man was in tears, and we essentially had to ban oncology from entering his room.

    It felt very odd to be in the position of protecting a patient from our colleagues.

  35. #35 ck
    June 14, 2009

    Dan,
    Put adriamycin on the code cart. Code leader: “1 amp epi, 1 amp bicarb, 100mg dox ivP…c’mon people…move!!!”

    Is you point that the “banned” oncologists didn’t have the patient’s best interest in mind?

    If not, what was their motivation? Please don’t say $$.

    Various treatments for “hepatic” cancer??? Was this before or after sorafenib?

  36. #36 Mark P
    June 15, 2009

    Donna B., Mark p is another example of someone who did not read the link to the Buckeye Surgeon’s blog posting.

    I did read it, and you and Donna B are just off track.

    I was discussing a side issue, about “What did the 80 year old man want”. It was not directly related to the original post, but I was unaware of any rule forbidding side discussion on this forum.

    Expensive treatment given to one person is, in effect, denied to another. It is, I believe, unethical to treat a person with no benefit even if that person is asked and agrees. This is, after all, what the woo-meisters do. So the issue isn’t just “ask the patient” at all.

    The issue of sensible treatment goes well beyond merely asking the patient what he/she wants.

    I don’t know the literature on what the costs of the US-American versus other medical systems are, but this statement sounds highly debatable to me.

    http://www.kff.org/insurance/snapshot/chcm010307oth.cfm

    http://masetto.sourceoecd.org/vl=3333764/cl=27/nw=1/rpsv/health2007/g2-1-01.htm

    There are issues of purchasing-parity reconciliations and Americans have a high rate of violent death, but the basic facts are fairly well known. The US has excellent health care for the top half, and much poorer than usual for a developed nation for the bottom half. That adds up to poor life expectancy figures etc. Yet the amount the US spends per person is very high.

    If you are looking for features that make US costs higher than the rest, I would suggest two features. The first is the lack of control the state has (setting prices, limiting unnecessary treatments, buying cheaper drugs). The second is the enormous insurance and legal costs of US hospitals and doctors.

  37. #37 Dianne
    June 15, 2009

    Is you point that the “banned” oncologists didn’t have the patient’s best interest in mind?

    If not, what was their motivation? Please don’t say $$.

    My reading of the comment, FWIW, is that the oncologists in question believed that they had the patient’s best interests at heart but were being extremely unrealistic about the overall situation. It may be that there is some detail we’re not hearing. Maybe they thought that they could get a cure. Maybe they were radically underemployed (HA, that’s likely in an academic medical center.) Maybe they were just in denial about the situation. Denial isn’t just a problem for patients and their families.

  38. #38 Dianne
    June 15, 2009

    Mark P: Thanks for the links, but I think my poorly worded comment sent you off looking for the wrong things…There’s no question that the US spends more money on health care than any other industrialized country. IIRC, it also spends more _public_ money on health care than any other country. The question is what is that money being spent on and how can it be spent more efficiently? The obvious huge variable is lack of universal health insurance in the US, but how exactly that translates into higher health care costs and how that interacts with the “defensive medicine” syndrome are less clear, at least to me.

  39. #39 Dan Hocson
    June 15, 2009

    This took place at the VA, so money was not an issue.

    At the time of presentation, the patient had a tumor the size of a large grapefruit in his liver, and mets to the lung and diaphragm.

    I don’t recall the specifics of the treatments suggested (this was in 1991), but what they proposed, by their own admission, would only add a few months to his expected survival.

    I think they were motivated out of a sense that “we can still do something for the patient”, but they failed to take into account the patient’s wishes.

  40. #40 Dianne
    June 18, 2009

    This took place at the VA, so money was not an issue.

    Sigh. I miss the VA. I’m right now facing a situation where a patient of mine may have life saving medical care denied or delayed because she has no insurance (it’s a procedure I’m not qualified to perform so can’t just do it myself and worry about payment later). I’m seriously contemplating just paying myself but I can’t do that for every patient…

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