Suggested Discussion Outline

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Suggested Discussion Outline

Post by johnkarls »

A. End-Of-Life Strategies Described By Our Author Atul Gawande

A-1. ICU – Hospital

A-2. Poorhouses = the norm before Social Security

A-3. Nursing Homes = the norm after 1934 when U.S. governmental funding became available for construction of “nursing homes” FOR THE STATED PURPOSE OF CLEARING OUT HOSPITAL BEDS (WHICH IS WHY THEY ARE CALLED NURSING HOMES!!!)

A-4. Assisted Living Facilities

A-5. Hospice Care

A-6. Assisted Suicide

B. Major Themes of Atul Gawande

B-1. The human body, like an old car, inevitably breaks down and does so in an increasingly myriad of ways

B-2. Medical doctors reflecting their training to save life at all costs, propose whatever treatment is available (and, if it proves ineffective, the next best treatment) regardless of how badly the quality of life is impaired and regardless of how little remaining life expectancy is extended

B-3. Nursing homes tended to be warehouses for the terminally ill until they die
B-3-a. The “three plagues of nursing homes” (p. 116) = boredom - loneliness - helplessness
B-3-b. But there is tremendous potential when residents are given a reason to live -- as demonstrated beginning in 1991 by Dr. Bill Thomas & his Chase Nursing Home (pp. 111-128) with simply putting plants in every room, parakeets in many rooms, and adopting 2 dogs and 4 cats for the entire facility -- all for the residents to care for

B-4. Assisted living facilities have tremendous potential when the needs and desires of the residents are honored

B-5. Hospice care is usually The Gold Standard when it is at all possible for the patient to remain in her/his own home

C. Major Criticisms by Atul Gawande

C-1. Medical doctors typically trying to save life at all costs, often “do harm” to patients vis-à-vis how their quality of life may be impaired

C-2. Medical doctors typically do NOT explain to patients vis-à-vis a possible treatment --

C-2-a. The chances of success
C-2-b. How much the quality of life may be reduced despite success
C-2-c. How little life expectancy is likely to be extended with success
C-2-d. Each side effect that may be encountered
C-2-e. How much the quality of life may be reduced by each side effect
C-2-f. The impact on life expectancy of each side effect

C-3. Hospice care

C-3-a. Typically very good at explaining a patient’s end-of-life options
C-3-b. However, distressingly-few patients ever get this far by escaping the medical profession’s more-treatment-at-all-costs modus operandi accompanied by uninformed unrealistic assumptions about what is likely to be achieved

D. Assisted Suicide

D-1. Atul Gawande spends little time (pp. 243-245) discussing it generally, though he does discuss it later in connection with his father's own death

D-2. Atul Gawande’s father (who was also a medical doctor), after surgery to remove as much as possible of a tumor growing INSIDE his spinal cord, permitted himself to be talked into radiation treatment which was wholly ineffective with disastrous side effects

D-3. Atul Gawande’s father, toward the end, told Atul Gawande that his overriding objective was to avoid pain and made Atul Gawande promise that he would put his father out of his misery when the pain could no longer be controlled

D-4. Although the description is a bit murky, it appears that Atul Gawande did NOT honor his father’s request for assisted suicide

E. Religion

E-1. Reading “between the lines” it appears that Atul Gawande’s father was a devout Hindu but that Atul Gawande himself was/is NOT religious in the least

E-2. So it is NOT surprising that Atul Gawande ignores completely how so many religious people are able to approach death with equanimity

F. The U.S. System of Ignoring Financial Costs vs. Benefits (if any)

F-1. Many other countries control costs by weighing carefully the financial costs vs. the benefits (if any) -- for example, admittedly extreme to illustrate the point, a 100-year-old person will not be given costly eye-transplant surgery even if the eyes come from a young relative who is terminally ill and will only consent for her/his eyes to be given to the 100-year-old

F-2. Such considerations were removed from Obamacare after the “death panel” attacks by opponents

F-3. Atul Gawande explains (pp. 174-175) that much the same result vis-à-vis private medical insurance followed the seminal 1993 lawsuit of the family of Nelene Fox who sued her California HMO for her death following a denial of an experimental treatment of high-dose chemotherapy accompanied by bone-marrow transplants -- receiving an $89 million jury award despite (per Atul Gawande) the experiments proving that the treatment was ineffective

F-3-a. NB: Atul Gwande’s explanation of Fox vs. Health Net does not seem to jibe with what we learned for our 9/10/2008 meeting when we focused on Michael Moore’s documentary “Sicko” that the way he gathered his material was by publicly soliciting “horror stories” of insurance companies refusing to pay for treatment

G. Possible Six-Degrees-Of-Separation E-mail Campaigns

G-1. Atul Gawande says (p. 153): “In the United States, 25% of all Medicare spending is for the 5% of patients who are in their final year of life, and most of that money goes for care in their last couple of months that is of little apparent benefit.”

G-2. Please noodle how this problem could be approached without encountering the “death panel” attacks

G-3. For example, would it be politically palatable to require patients facing expensive treatment to have explained to them --

G-3-a. The chances of success
G-3-b. How much the quality of life may be reduced despite success
G-3-c. How little life expectancy is likely to be extended with success
G-3-d. Each side effect that may be encountered
G-3-e. How much the quality of life may be reduced by each side effect
G-3-f. The impact on life expectancy of each side effect

G-4. Also for example, would it make sense to provide very-liberal health-savings-account rules where any unused balance can be left to heirs -- so that the patient has an appreciation of how much treatment will cost vs. the probable benefits (if any)???

G-4-a. NB: It should NOT be a valid criticism of this proposal that beneficiaries of other governmental programs (e.g., Medicare) can obtain treatment regardless of cost, since this is merely a question of how to coordinate the two

G-5. Any other campaign topics relating to cost containment???

G-6. Any other campaign topics not relating to cost containment???

Tucker Gurney
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Palliative Care Decision Making Reported In Being Mortal

Post by Tucker Gurney »

The following palliative-care decision-making questions recommended by Susan Block were reported by Atul Gawande in Being Mortal:

1. What is your understanding of what is happening to you?

2. What are your fears if that should happen?

3. What are your goals if your condition worsens?

4. What trade-offs are you willing to make and not willing to make to try to stop what is happening to you? For example, can you accept paralysis? 24 hour nursing care? a ventilator? a feeding tube? mental incapacity?

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