During today’s 60 Minutes, ‘Aid in Dying’ addresses what advocates call "death with dignity” and opponents call "assisted suicide." Dr. Eric Walsh of Oregon speaks about this controversial practice with CBS News chief medical correspondent Dr. Jon LaPook. CBS also speaks with the husband of Brittany Maynard whose final days received national attention in 2014.
As would be expected, there is controversy about the issue with strong feelings on both sides. Yet, in the five states where assisted suicide is legal, they represent just 0.2% of all deaths. Meanwhile, for the 99.8% of deaths that are “normal”, far too many deaths can only be described as ‘death without dignity’ and there’s little disagreement that our failing system strips humanity away from both patients and doctors. On the subject of dying, our healthcare system is falling far, far, far short of what we should expect.
Misery we wouldn’t inflict on a terrorist
In his powerful essay in the Saturday Evening Post and the Wall Street Journal, Dr. Ken Murray outlined how doctors die differently from the rest of us.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
Almost all medical professionals have seen too much of what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
Nurses and doctors are aware of how pervasive this dynamic is. Unfortunately, failing to change our system has devastating consequences.
Filling the equivalent of Arlington National Cemetery every year
I wrote earlier that the National Library of Medicine, Pro Publica and others have published that the number of preventable patient deaths associated with hospital care every year is 440,000. In addition, there are approximately 4 million preventable major complications per year. To put that in perspective, each year preventable hospital deaths are more than the equivalent of all of the soldiers buried in Arlington National Cemetery. It’s also more than the total number of U.S. deaths from World War II. Major complications are also more than four times the total number of U.S. casualties from WWII (one million).
An example of what we do to seniors is told by Shannon Brownlee of the Lown Institute in her story about the healthy 88 year old vet who’d survived Normandy but over-treatment led to unrelenting diarrhea for the last 6 months of his life. No one should die like that -- especially a veteran who put their life on the line for their country. Overtreatment is so pervasive that it is the primary focus of the Lown Institute (founded/named after Dr. Bernard Lown, the inventor of the artificial defibrillator) through their Right Care Alliance campaign.
Restoring humanity to healthcare
The U.S. should follow the lead of La Crosse, Wisconsin or the recommendations made by Dr. Atul Gawande in his book, Being Mortal. As Dr. Ted Epperly (former American Academy of Family Physicians president) shared with me, at the end of one’s life most people’s needs are quite simple — people want to be warm, dry, pain-free and with loved ones. In La Crosse, Gundersen Health System pioneered the Respecting Choices program to change the status quo. In fact, in La Crosse, you're unusual if you don't have a plan for your death -- 96 percent of people who die in La Crosse have an advance directive or similar documentation compared to 30% nationally. Everyone is far happier — providers, family members and the patients themselves. As a nice byproduct, this has resulted in a 40% per capita savings on Medicare compared to the nation as a whole.
I’m currently working with the Oscar-nominated, Peabody-winning film-making team behind some of the iconic documentaries and TV shows in recent memory. The Healthcare Heist documentary hopes to have the same kind of impact that Super Size Me and An Inconvenient Truth had in raising the public consciousness about what we believe is the single greatest immediate threat to the American Dream. It will show both the dysfunction and brilliance that creates what amounts to two different healthcare systems. The brilliance exhibited in healthcare is the blueprint for the open source Health Rosetta that shows that every structural fix necessary for healthcare to realize its full potential has already been invented, proven and modestly scaled.
Recently, we had the opportunity to speak with the architect of the Respecting Choices program, Bud Hammes. Hammes found frequent moral distress among the clinicians dealing with these end of life issues; however, they didn't feel like they had a choice but do "everything possible". One doctor felt like he was being asked to physically beat up old people. They had felt powerless even though they didn't see the value of intubation & CPR yet felt obligated to take measures they’d never want on themselves.
[Disclosure: As I've disclosed many times, the Health Rosetta is a non-commercial open-source project that provides a reference model for how purchasers of healthcare should procure health services. In my role as managing partner of Healthfundr, a seed stage venture fund, the Health Rosetta is the foundation of our investment thesis.]
In the status quo healthcare system, when it comes to aging and end-of-life, the status quo could be summarized as follows:
- Individuals and families are left to fend for themselves at the most stressful moment in their lives.
- Healthcare delivery systems and community goals are not in sync.
In contrast, with the Health Rosetta, the following summarizes how much better things can be:
- Community culture and resources aligned to optimize a quality Elderhood that leaders such as Dr. Bill Thomas are taking across the country
- Key initiatives such as Green Houses are broadly adopted and there is provider adherence to Advance Directives
While issues such as assisted suicide can be controversial, there is no controversy that clinicians would like to be able to respect people's wishes. So far, 125 medical facilities and several countries have adopted the Respecting Choices program.
Hammes described how the culture drove a shift. The question was no longer ‘how to treat your disease’, it was ‘what is important to you?’ This is a big shift. As long as we focus on diseases, the bias is towards treatment. The key is how you frame the question. It causes people to think differently about their choices and what matters to them.
Providing the best medical care means not just using the latest technology but using technology appropriately to accomplish what is important to patients as people, not diseases.
This article was also published in Forbes
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