Archive for category Medical futility

Advance Care Planning — one more CPT code

cptbookThe AMA has 7,800 codes for all types of medical services.  Discussion of end-of-life care has been considered part of routine primary care.  Now, the medical-industrial-complex wants another fee for the service of discussing this topic.

The service in question is “Advance Care Planning“.  Certainly, a good idea — a health care provider should be talking with patients about end of life issues.  We all die, that seems obvious, but someone should ask: “when it does happen where do you want to be, who would you like to be there, and have you told someone about your wishes for medical care at the end?

Virtually anybody can ask those simple questions.  Sure, getting up the nerve to ask the questions is hard for family members.  And, sometimes there is no family to discuss the questions or the answers.  Like other issues of health care, the primary care provider should broach the questions and record the answers and facilitate discussions with the people close to the patient.  It’s not a question that needs repeating at every visit, but periodically as conditions change.    Is the discussion important?  Absolutely.  Soap operas are not where the answers exist.

There is an undercurrent of distrust.  The distrust is because the medical profession seems so motivated by profit they may do unnecessary treatments when death is near.  Thus, to avoid unnecessary treatment a person must clearly state what medical services are wanted at the end of life.

The issue is clouded by the huge shift in the doctor-patient-relationship over the past 10 years.  The doctor who might see the patient in the primary care outpatient clinic is not the one who will see the patient at the care center, or the oncology clinic or be the admitting physician at the hospital.  Unless the patient, family and friends have a clear grasp on what the patient wants the information may be lost or be misrepresented.  It would be incorrect to think the medical record will be universally available — it’s not now and will probably not be that way for decades (if ever).

An equally difficult problem is the “grey area” between care that works and futile care.  “Is this the end?”   The care provider who is asked that question is really on the front line, not the primary care provider who discussed the issue 10 years before.

The elephant in the room is the cost of care.  And, the fact many people do not have the resources to pay tens of thousands of dollars a month for care when their income is just Social Security.  Very few people say “do everything”.  But, can a person with no resources actually say “do everything” and expect that to happen?

The bottom line:  the new CPT codes pay for something a primary care provider should already be doing so the additional cost is not needed.  If the discussion is not happening then it is a case of poor quality primary care.  Paying more never makes low quality care better, it just makes poor quality care more expensive.

An end-of-life discussion with a knowledgeable provider tends to set expectations in a reasonable range.  Satisfaction with medical care is often about meeting expectations, so this is important for the patient and the care providers.  It also should set expectations for friends and family — after the patient dies they are the ones who decide if expectations are met.

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Medical Futility — drawing the line

icuToday’s medical futility is tomorrow’s routine care.   A very hopeful thought.  However, in the present consider a modern intensive care unit.  A treatment area in most hospitals where a month of care could easily cost half a million dollars.   That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.

Cost is the most important factor to consider in a discussion of medical futility.  Futility means doing something that will fail.  Of course, our modern definition is doing something that will likely fail but might not if we spend enough money.  If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile.  But,  if it costs ten million pennies …  we think about futility.

American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven.   Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”.  Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.

The same question of effectiveness exists for intensive care.  It’s clearly not for every patient,  just a select few.  But, how are doctors identifying  those select few?

Critical illness is fraught with uncertainty.  We have lots of expensive treatments but where do we draw the line.  Deploy the technology or let nature take it’s course?   Ethicists and theologians suggest they know the answers.

Yet, patients and families seek a pragmatic solution:  grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?

Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty.   They tend to favor using their skills to “give it a try” and make money doing so.  But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road.  The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.

Critical care is extremely stressful to the body.  Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months.  So, even walking out of the hospital after critical illness is not a guaranteed success.

Back to the question of futility.  Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor.  This is when going to a hospital with a high quality score is important.   There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care.  This is one time “ask your doctor” is exactly the right thing to do — listen carefully.

 

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