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Demystifying Medicine One Week at a Time

Tag: NYTimes

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Defeating the Purpose

The Affordable Care Act. Obamacare.

No matter what you call it, the law has two main goals: Insure more (all?) Americans, and in doing so, lower the aggregate costs of health care in the U.S.

money in the handsAfter year one of the Act’s main rollout, there is no doubt about the first goal—millions more Americans now have health insurance. Many have purchased it on the “exchanges,” whether they are state run (best example might be Kentucky) or run by the federal government (think “Healthcare.gov”). Millions more are now covered by Medicaid, the 1960s-era federal program (which also uses state matching funds) to insure the poor.

The jury is still out on whether the law will lower costs. In principle, insuring more people lessens costs by bringing more healthy people under the insurers’ umbrella, thereby spreading risk more effectively and using more (but smaller individual) premium payments to provide care to more individuals in a group market setting. More buying power, and more ‘market efficiencies’ (see automation and digitalization of health care, as well as streamlining of processes) in theory lower the aggregate costs.

Another way in which insuring more people while costing less occurs is by providing insurance that people don’t use. When we don’t use our health plans, the overall spending in the system goes down. Obstacles to using health insurance include co-pays (the out-of-pocket portion of health costs that insurance doesn’t cover) and deductibles (an annual out-of-pocket amount that you must spend before your insurance ‘kicks in’).

In a solid analysis of this situation, the NYTimes ran a front-pager demonstrating how the new plans use tiered deductibles—which have the net effect of dissuading people from using their insurance.

Remember that everyone has the ‘right’ (in fact the responsibility, i.e. the ‘mandate’) under the law to purchase an ‘affordable’ plan, tiered as platinum, gold, silver, or bronze. [This does not apply if you a) have insurance through your employer or b) you qualify for Medicaid.]

The platinum plans cost the most up front, but have the least in terms of deductibles and co-pays. Just the opposite for the bronze plans, the most ‘affordable,’—i.e. the ones with the lowest annual premiums. The problem with these is that it turns out the deductibles can be so high as to impede people’s use of the insurance. It’s in effect an insurmountable hurdle to using newly-gained health insurance.

Here’s an excerpt from the article to give you the idea:

Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.

“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ ”

Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said — for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”

How can we make this system work better?

Age is Just a Number, Right?

In case you missed them, a couple of lay press articles hammered home the idea of our lifespans being finite.

ezekiel_emanuel_0First there was Zeke Emanuel’s provocatively titled “Why I Hope to Die at 75” in the Atlantic.

The title was unnecessarily inflammatory. A lot of people saw that and thought “Health Care Rationing…” and “what a jerk!

One of the core points of his article is well-taken: when we hit a certain age (75? 80? 85?), it no longer makes sense to “look for disease.”

Health care must continue improving and striving to reflect and honor the wishes of patients, but in addition, we should be more rational about whom we screen for disease and how often. It makes no sense to perform colonscopies in octogenarians to “screen” for colon cancer. Even if they have it, the colonoscopy  is unlikely to extend their life or improve its quality.

I think readers are right to quibble with Emanuel’s contention that at 75 creativity takes a nose dive. He was using that opinion, and the statistical evidence of age-related slowdown, in support of his point about the cutoff age for aggressive medical care. I hope sensible debate is not lost because of his tone and the fact that he’s seen as too political. He did work for the administration during President Obama’s first term, after all.

cohen-01-by_david_boswell

Cohen in younger days.

That same week, the New York Times published an opinion piece by Jason Karlawash of Penn, who wrote about musician Leonard Cohen’s decision to resume smoking (something he’d quit) upon turning 80. Titled “Too Young to Die, Too Old to Worry,” Karlawash examined how the 80+ population has grown from a half of one percent of the population to more than 3.5%. Doesn’t seem like a huge percentage, but it is certainly a significant increase and a huge demographic shift.

As Karlawash writes in the key paragraph of his piece

…Mr. Cohen’s plan presents a provocative question: When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?

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