Life in the slow lane
As disagreements about universal health care shape the political scene, voters shrink from the idea of rationing services. It seems to be our main criticism of many foreign countries that have had universal coverage for years. Little complaint comes from the folks who live in those countries. Most comes indirectly from this country’s insurance industry lobbyists and Big Pharma.
That’s to be expected. When profits, and the structure from which those profits grow, are threatened, the profit makers fight to defend the status quo. Most countries with universal insurance coverage have laws against for-profit medical insurance.
As the debate continues, as it surely will, we may be hearing more about “slow medicine.” Defined as a backing off from high-intensity treatment of elderly patients, the practice focuses more on providing comfort than cures. And it is becoming a viable option for many patients in nursing homes.
However, for those still living in their own homes or with relatives, and those in assisted living facilities, that option may not exist. In case of a medical incident, such patients will usually be subjected to an ambulance ride and wind up in a hospital emergency room. Once there, they’re told they must have pricy diagnostic tests and aggressive treatment, often for conditions quietly deemed terminal. Extricating oneself from the system can be wrenching at best and often virtually impossible. And patients are rarely told when their condition is incurable. So they suffer needless procedures and are offered treatments that have little chance of success.
All of this costs taxpayers billions and undermines the solvency of Medicare.
A recent report in the New York Times describes the policy at a New Hampshire retirement community affiliated with Dartmouth Medical School. Kendal at Hanover has become a laboratory for the slow-medicine movement, the report states.
At Kendal, it is possible (even routine) for residents to decline hospitalization, tests, surgery and medication. Even nutrition can be refused.
UCLA’s chief medical officer has described aggressive treatment for the elderly at acute-care hospitals as often “inhumane.” Dr. Tom Rosenthal explains that our culture has a built-in bias that everything that can be done will be done, and that the fast pace at which such hospitals operate discourages meaningful discussions between doctors and patients or their relatives.
That means explaining that CPR rarely saves elderly people from cardiac arrest, and that a woman who has a hip fracture may never walk again, even if the hip is surgically repaired. And surgery itself often begins the downward spiral that leads to death within a year for many such patients, exacerbating heart problems, causing blood clots and strokes, and hastening dementia.
Statistics seem to support the slow approach. Nine out of 10 people who live past 80 will become unable to care for themselves because of frailty or dementia. So doctors who push medical interventions to patients with multiple chronic illnesses run the risk of extending a life that some feel isn’t worth living. The impact on patients and their families can be devastating. The financial burden on Medicare will become unsustainable as our population ages and the baby-boom generation retires.
The term slow medicine was coined by Dr. Dennis McCullough in his book, “My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your Aging Loved One.”
Having watched the agonizing decline of my mother after surgery to repair a hip fracture, I can appreciate what McCullough proposes. Confined to a nursing home with confusion from a small stroke and worsening emphysema, she was rushed to an emergency room one night as her lungs filled with fluid. She thought she had an agreement with her doctor that no heroic measures would be used to extend her life. My two sisters and I understood that she was ready to die and, in fact, welcomed death. But when we returned to the hospital the next day, she was lying in the ICU, tubes in her throat and tears in her eyes. Sometime during the night, doctors prevailed upon her to allow a respiratory procedure she didn’t want. She was returned to the nursing home a few days later, furious about what had happened. “I can’t believe I’m still here,” she moaned. She had been coerced into accepting the heroic measures she hoped to avoid. She died a few months later without ever leaving the nursing home or resuming anything resembling a normal life. What a shame.
As the country inches its way toward universal health care, we probably should pay close attention to the different proposals, and to the role insurance companies might have in writing the rules. In the countries where health coverage is an entitlement paid through taxes there are no bankruptcies caused by medical bills. There are also no liver transplants for 90-year-old alcoholics. Some rationing is a fact accepted by most as a reasonable reality.
Perhaps in this country, the slow medicine movement may resolve many issues about limiting interventions for elderly patients with chronic illness. It also might allay fears that insurance companies are rationing certain procedures, and shift responsibility for such decisions to doctors, patients and their families.
That would be a positive step.