??and all I ask of dyin?, is to go naturally? * | Raucous Caucus | Tom Cushing | DanvilleSanRamon.com |

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About this blog: The Raucous Caucus shares the southpaw perspectives of this Boomer on the state of the nation, the world, and, sometimes, other stuff. I enjoy crafting it to keep current, and occasionally to rant on some issue I care about deeply...  (More)

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??and all I ask of dyin?, is to go naturally? *

Uploaded: Sep 20, 2014
We don't die well in America -- treating it as a tragedy to be avoided, rather than as a natural inevitability that ought to make every healthy moment consciously more precious. Over $50 Billion (by some estimates half of all Medicare costs) annually is devoted to patients who will die within two months of treatment. That is not to say that all such money is wasted, nor that 'panels' should ration care, Mrs. Palin. It does beg the question, however, of whether that 'investment' is well-made ? defining that term as 'in keeping with the patient's actual wishes.'

Our cultural approach to the subject needs a re-invention from stem to stern (including true euthanasia, thinks I, with a few appropriate safeguards against the impatience of expectant heirs). Instead, we avoid even thinking about it, much less taking steps to ensure that our wishes will be granted -- especially in case we may later be unable to express them. Some religious traditions facilitate that willful procrastination in the belief that choosing the moment of each person's passing is the province of the divine (personally, I wouldn't presume to bother my deity with it ? there must be much better uses of immaculate time and attention).

The Institute of Medicine (an affiliate of the National Academy of Sciences) made a small dent in the problem this week, issuing a lengthy report titled "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." The report questions the wisdom of treatment that extends chronological life, irrespective of its quality. It notes that terminal patients typically receive high incidences of preventable hospitalizations. ICU costs often exceed $10,000/day, and treatment is administered by specialists unknown to the patient (if sentient) and by alien machinery.

By contrast, so-called palliative care that focuses on comfort and emotional support is associated with higher quality of the life that remains for the patient. The report indicates that those who receive palliation also may even live longer on average than patients who do not receive such care. That sounds like a pretty good, last deal ? so why isn't it the medical industry standard?

Enter the facts that 1 -- most end-of-lifers are not in a position to make immediate decisions about their care, and 2 -- the 'default mode' of treatment in such cases is 'acute care.' That's another term for multiple procedures conducted in a fee-for-service environment, done most efficiently in a hospital setting. Docs are pretty good at those individual, Small Picture procedures, even if they can be over-zealously performed (e.g., a 60 Minutes report of a pap smear done on a octogenerienne, who was dying of a hospital-acquired infection). The patient's Big Picture interests can get ignored in the process.

Thus, 'advance care planning' is essential to ensure that patients receive the care they actually want, based on decisions they make when they are best able to do so. But we avoid those conversations ? seeing them as 'awfully awkward' when they ought to be considered 'awfully damned important,' instead.

The Report recommends several far-reaching changes to the current medical industry status quo.

1 ? end-of-life patients should be covered by their insurers (public and private) for "comprehensive" care that integrates all their needs: physical, emotional, social and spiritual, with access to palliative care as consistent with each individual's expressed, informed preferences. Palliative care should be coordinated among small-picture experts with the ultimate quality-of-life goal in mind.

2 ? there should be a major push for advance care planning, with quality treatment standards established that are "measurable, actionable and evidence-based." These standards should kick-in as early as children can reasonably make their own decisions, and continue throughout as part of the way folks conduct their whole lives. Clinicians should be responsible to initiate these planning processes, and integrate them into their routine patient relationships.

3 ? The medical Establishments ? from med schools through certifiers to health care deliverers -- should mobilize to develop appropriate training in both palliative care and patient communication skills, both of which are lacking in current curricula and processes.

4 ? policies and payment systems should be brought in-line to respond to patients' "values, goals, informed preferences, condition, circumstances and needs" ? thus reducing acute care crises and unnecessary, non-value-adding expense.

5 ? there needs to be a massive mobilization of "civic leaders, public health and other governmental agencies, community-based organizations, faith-based organizations, consumer groups, health care delivery organizations, payers, employers, and professional societies" (read: 'everybody'), to sea-change our cultural approach to the concept of death. The goal of this national conversation needs to be to encourage conscious, comprehensive and informed consideration of options for end-of-life care.

This is such a rational, sensible, humane and cost-saving set of proposals that the cynical temptation is to conclude there's simply no chance of its coming to pass. I do fear that major obstacles include both inertia, and the fact that SOMEbody is making a potload of money on all that late-inning acute care.

That said, I hope this effort succeeds. In my own perfect world, with those two months left in my local tenure, I'd be presented with the choice of a check for $100,000 and a happy pill on one hand, or some gruesome course of treatment on the other (hold the prostate exam, please). From this vantage, that pill looks pretty good.

In the world that actually exists, I'm calling my doc on Monday. We need to talk.

*Laura Nyro/Blood Sweat and Tears: "And When I Die"
What is it worth to you?


Posted by Cholo, a resident of Livermore,
on Sep 20, 2014 at 9:09 am

Re: Poor people/Euthanasia

I hope that a lethal does will not be seen as a way of saving money on palliative care for those that cannot afford to pay for it.

Posted by Cholo, a resident of Livermore,
on Sep 20, 2014 at 9:20 am

Palliative v. Hospice care: Is there a difference?

If the patient has advanced dementia along with other serious illnesses, how do you identify the palliative needs caused by the dementia?

Posted by Cholo, a resident of Livermore,
on Sep 20, 2014 at 9:26 am

1st post spelling correction - I hope that a lethal dose...

Posted by Pololo Mololo, a resident of Livermore,
on Sep 20, 2014 at 9:58 am

just gotta ask...if a doc gives a patient a lethal dose...will he/she go to prison? who administers the lethal dose?

i don't want anybody giving me a lethal does of anything...i'm more concerned about pain mgt.

lots of nazi docs in argentina freely offered lethal doses to political dissidents before and after the dirty war...nothing happened to the docs...the us government didn't exhibit any concern...henry kissinger never complained?

seems to me that if the poor are more commonly offered a lethal dose and not pain mgt., the gov't. will save lots of money...hmmmmmmmmmm...

does anybody know if a "lethal dose" ever fails...the patient survive...but looks like a veggie...do they then get a second chance to be taken out?

this whole business seems way spooky to me...i guess the best thing thing to do is to make sure you don't die?

does anybody believe that consulting with an attorney will help...i don't!

Posted by It is expensive , a resident of Birdland,
on Sep 20, 2014 at 11:43 am

The cost of health care these days is too expensive. I like Cholo's point of view on the issue, it is too bad Cholo is now banned from posting in the town square.... looks like he will start to comment in the blogs...

Posted by Tom Cushing, a resident of Alamo,
on Sep 20, 2014 at 2:14 pm

Hiya Cholo: I do not know the specific answer on palliative care. Perhaps someone else does?

Posted by Realist, a resident of Another Pleasanton neighborhood,
on Sep 20, 2014 at 5:37 pm

I'll choose the natural route also. Palliative means improving quality of what is left of that life. So I would assume that includes Hospice. I have been following the series of articles and studies on this topic, simply because this country does not deal with it very logically. Usually euthanasia doesn't enter the discussion. Euthanasia has nothing to do with mechanics and the two very different issues should never be confused.
Much too often individuals are 'hooked up' without much thought. I have problems with religious hypocrites who says God rules their lives, then want the doctor to hook up a parent, instead of leaving it in God's hands. Unless they will also call for unhooking, they should not go for artificial mechanics in the first place. That is not living. I do not think grandparents want to blow their grandkids college fund. Hookups of undetermined time should not be paid by medicare. Joan R and daughter understood 'quality of life'. I admire the film Joan made explaining quality of life. Perfect.
Seniors should be allowed the dignity of comfortably passing naturally, and in a familiar setting....like it used to be whenever possible. Torturing elders by repeatedly running them from nursing home to hospital is not a loving action. It is simply 'prolonging dying'. Ask yourself if you would like a long, torturous death, or swift and peaceful passing. Death is the flip side of the life coin.
Maybe it is time for 'Soylent Green' to be RE-released.

Posted by San Ramon Observer, a resident of San Ramon,
on Sep 21, 2014 at 12:07 am

San Ramon Observer is a registered user.

My mother is in a Life Care facility. It goes from Independent Living, where she is now, to Dependent Living, to Barely Living, and then you're done.

I've thinking about moving there too.


Posted by Diane, a resident of Danville,
on Sep 21, 2014 at 8:26 am

Palliative care refers to comfort measures related to serious (not necessarily end of life) medical conditions and can be provided at any point in one's life. Hospice care is end of life care, in which the focus is on palliative measures.

MediCare (for those over 65 and/or those who have been disabled for 24 months) and Medi Cal (needs based medical coverage) both have hospice benefits, so hopefully our elder population as well as the indigent population would be able to access hospice care if desired.

I'm with you, Tom. I believe that we as a culture tend to prolong a suffering death. I've completed my advanced directives along with a 5 Wishes document. Highly recommended.

Posted by Tom Cushing, a resident of Alamo,
on Sep 21, 2014 at 9:25 am

Thanks, Diane. Five Wishes was unfamiliar to me, so here's a link for further exploration (no implied endorsement, yada yada): Web Link

Posted by San Ramon Observer, a resident of San Ramon,
on Sep 21, 2014 at 1:23 pm

San Ramon Observer is a registered user.

Diane & Tom,

Thanks for the info on Five Wishes. I never heard of it before either. I will look into it further. I bought an Estate Plan and Will software a few years ago and still haven't filled it out. I need to start planning soon.


Posted by Herman Glates, a resident of Danville,
on Sep 22, 2014 at 2:37 pm

You?re back??

I thought we finally succeeded and you gave up.

Guess I?ll have to try to be more annoying.

Posted by Tom Cushing, a resident of Alamo,
on Sep 22, 2014 at 3:18 pm

HIya S-P: I haven't compiled a Top 5 Most Annoying list, but I doubt you'd rank that high. You're too on-point. Others have striven far harder -- and succeeded sometimes, too. But it's tough to nail down how many of them are just schizoid variations on the same individual.

Please don't misinterpret this post as a request that you compete for the title. You're a talented guy -- I'm certain you're capable of it.

So, do you have an advanced care directive?

Posted by Herman Glates, a resident of Danville,
on Sep 22, 2014 at 6:56 pm

This topic is too boring for me to comment.

Posted by San Ramon Observer, a resident of San Ramon,
on Sep 26, 2014 at 3:06 pm

San Ramon Observer is a registered user.

My grandmother was 70 years older than I. She lived with my parents since before I was born. She was 98 when she had some kind of seizure.

I called an ambulance and had grandma taken to New Rochelle Hospital. A Doctor there asked if I wanted to put her on life support. She was 98 and frail for Pete's sakes. I said, "Good heavens, no!" So they didn't and she died peacefully as she should.

My parents were on a cruise and in Turkey at the time. I contacted them via telegram and they made arrangements to fly home. I made arrangements for the funeral, which we held when mother and pop got back. It was the right thing to do.


Posted by Diane, a resident of Danville,
on Sep 26, 2014 at 3:17 pm

That's a wonderful way to go, Roz! Sounds like your grandmother had the right person looking out for her. Unfortunately, absent clear advanced directives, it often doesn't work out nearly as well and the ill person can be placed on life support regardless of the wishes of the family. It can save the family much traumatic guess work and arguing with hospital staff if we complete our wishes and provide copies to our physicians and loved ones before such a catastrophic event.

Posted by Charles74, a resident of California Somerset,
on Jun 15, 2016 at 9:17 am

Blood, Sweat And Tears - just listened to the Greatest hits album Web Link really like it

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