Monday, March 21, 2011

Should We Ration Medical Care?

I will be 65 in August and that means Medicare. I get information in the mail almost every day regarding Medicare, mostly from companies that want to sell me a supplemental health insurance policy. I know, first-hand, that Medicare is not as generous as it used to be because I have a 91-year-old mother and I've been told a number of times by doctors - "Medicare won't approve that test/treatment." Or Medicare won't pay for your mother staying in the hospital any longer."

Even though I'm almost 65 and soon to be on Medicare - and even though Mom is 91 and has been on Medicare for decades - I actually agree with rationing health care. To tell you the truth, I've always thought it was odd that, as a country, we chose to cover all of our elderly people instead of all of our children. In effect, we invest more in the past than in the future.

I know the rationale is that old people, yes, like me, have worked hard all their lives and at a certain age, they are on fixed incomes and helpless to earn enough to pay for their own health care so, as a society, we owe them. But if senior citizens are helpless, children are even more so.

The fact is that we pay the most medical costs for seniors in the last years of their lives. We spend those dollars on people who aren't going to get well and return to active living. My father-in-law is an example. He was in the nursing home with Paget's Disease, an extremely painful and incurable condition requiring lots of specialized and expensive treatment. He was rushed to the hospital with an aneurysm. He was stabilized in the emergency room, then transferred to Intensive Care where he spent several days. Eventually, he was returned to the nursing home where he lived another agonizing year.....at a cost of many, many tens of thousands of dollars to the taxpayers.

Should we have gone the extra mile to save him? I don't think so. I would say the same if it was my mother. I hope I'd be courageous enough to say the same if it was me.

Mom and I both have living wills that will hopefully prevent that kind of situation. No heroic efforts to prolong life. No feeding tube to keep us hanging on indefinitely if we're unlikely to return to a life worth living.

What we should be able to expect is comfort care. We shouldn't have to endure intolerable pain.

Mom was in a wreck a few weeks ago. She was taken to the emergency room where tests were done. "No broken bones," they told us, "no internal injuries." Just extremely deep and severe bruising. "She'll be sore for a while."

And she was. I had to help her turn over in bed, assist her to the bathroom. She didn't complain. After all, we'd been warned what to expect. Two weeks later, the pain was as bad as ever and she was plagued with constant vomiting. She was crying in despair. "I just can't go on hurting so bad and being so sick."

I took her to the emergency room again. They patted her on the head and essentially said, "now, Honey, we told you you'd be sore." But they did more tests. The doctor came in looking rather sheepish. "No wonder you hurt, you have four broken ribs. We missed them the first time around."

He gave her stronger pain medication and sent her home. It didn't help. I could see her going downhill. I took her back to the emergency room and this time I threw a fit.

"I can't get her to eat or drink anything. I think she's getting dehydrated. I want her in the hospital where professionals can take care of her!"

He said she didn't meet Medicare's criteria for keeping her. I told him, "then find whatever hook you need to hang it on, just do it!"

They admitted her for a 23-hour observation. They hooked her up to intravenous fluids. They put pain medication and anti-nausea medication in her intravenous tube. By the time, I brought her home 23 hours later, she was in good spirits. Her suffering had been alleviated; her vomiting had stopped. She'd been re-hydrated. She'd gotten a good night of rest.

That's what I mean by comfort care. Not only is it kind but it is cost-effective. I'd asked the doctor, "what happens if she gets completely dehydrated and the vomiting continues."

"Bring her back. If she gets that far down, we can admit her."

"Won't she be here longer if that happens? Why not admit her now and prevent that from occurring?"

The way we do it now is ass-backwards, waiting until a patient is so far down, desperate measures are required.

It used to be that people got old and then they died of what we considered then, natural causes. Now, we make extreme efforts not to allow people to die of natural causes. We put them in acute care and hook them up to unnatural tubes and machines. My father always swore he'd haunt me if I allowed him to be put in that position. Fortunately, he died of a massive myocardial infarction at home in his own bed. I hope the same thing happens to Mom but if it doesn't, what I want for her (and me) is to be able slide away from this earth pain-free.

Medicare is one cause of our huge national deficit. I don't go as far as putting our old people on ice floes to die as the Eskimos used to do but I think commonsense dictates that we stop spending so much money we can't afford on people who aren't going to return to good health whatever we do.

The Republicans hate national health care but one of their big gripes about Obama's health care plan was so-called Death Courts. They ranted and raved about the immorality of judging who deserves to live or die. (Myself, I think the medical community is perfectly capable of making that decision). I guess the Republicans believe the moral stance is to do without healthcare altogether and let God decide....even if that means untold suffering prior to death. They can't make up their minds. They want the Terri Schiavo's to be kept alive forever but they evidently don't want to pay for it. So which is it?

My vote is for directing more of our scarce healthcare dollars to the early years of life and fewer of them to the final years. Those of us who are of Medicare age have had the opportunity to live our lives. Children still have their futures ahead of them.