Health Care Reform — a l'Americaine
As I begin my first blog, it seems appropriate to talk about one of the most pressing issues in American society — health care reform and how it’s being defined in our society and by the new Administration. Don’t get me wrong. I’m all for letting the new president go at it. But how is the problem being defined? What’s being discussed? What’s being left out? Like the kind of national tax supported health care system every other developed country has — except our’s. But more on that in another blog. What I want to talk about now are some of the hidden cost escalators in the system and why they are rarely included in the discussion about generating the kinds of cost-savings that would allow us all the get the kind of high quality care we need.
What’s rarely put on the table is the scandalous over-use of health care resources in futile care that simply drives people into the ground. Here’s an example. She’s a 91 year old woman had a triple A — an abdominal aortic aneuryism. She’s operated on — of course — recovers slightly and then begins to decline. One thing after another happens — falls, infections, paralysis that no one can figure out. Things go from bad to worse to worst. There is no significant involvement of a primary care provider. No one in the family is willing to discuss DNR (Do Not Resussitate) not to mention Do Not Hospitalize. No one is reading the excellent Handbook for Mortals by Joanne Lynn and Joan Harrold. (Instead of getting an offer for AARP membership when you’re in your fifties, we should all receive a free copy of this book, courteous of a government that really wants to save money). The woman goes from hospital to home, from home to nursing home, from nursing home to hospital. Etc. Finally, a few weeks before she dies, physicians find what might be (might being the operative word here) a tumor on her spine. So it’s into the OR for her. Guess what? No tumor. She does, however, end up on the ICU, develops pneumonia. She’s transferred yet again to a different hospital where the brilliant new ( the family has by this time lost count on how many doctors have been “in charge”) physician takes over and discontinues the anti-biotic and her infection really takes off. Finally, by the last day of her life, more heroic measures are proposed and finally — finally after months — the family is ready to get the message that someone with some time and empathy could have conveyed months earlier — the 91 woman is going to die. They actually beg for mercy and she dies that same day. Hearing the story I was reminded of poor George Washington’s horrendous last days when physicians bled him almost to death and he just begged STOP!!! THE TORTURE!!! and died.
Only more than 200 years later the torture is a lot worse and a whole lot more expensive. I can’t imagine what the cost of this exercise in futility came to. $500,000? A little more? A little less? This family suffered needlessly because no one had the time or expertise to have a serious talk about the facts of life — one of which is that none of us make it out of here alive. More to the point — and this is the horrible thing — the system and all its players benefit from this drawn out kind of death. Every time the doctor visited, there was a charge. Every time she was put on a IV drip, someone benefited. All those anti-biotics sold, all those dollars gained by some institution or other.
How many people — young and old — go through that experience every single day because doctors aren’t trained (and I use that word advisedly) to deal with death. Because we don’t have enough primary care providers and at least some of them (like the one who was supposed to take care of this woman) are missing in action. Because nurses aren’t empowered to say, “stop the action.” There are so many cases like this. The New York Times did an incredible front page story on the unnecessary and exorbitantly expensive ($100 million a year) use of cardiac CT scans — scans that actually deliver more than 200 worth of X-Rays at one time — usually for no clinical benefit. Yet Medicare — after announcing it would not pay for the scans — copped to pressure from cardiologists and said, okay, you can do them in spite of the fact that there is no evidence of benefit and only evidence of harm. So now we, the taxpayers, are giving cardiologists federal money so, like the leaders of the nation’s collapsing banks, they can use it for the equivalent of hefty bonuses. Does this make sense? When are we going to stop using our now very scarce resources like this and start a national conversation about using them more wisely. If discussions about health care reform don’t include topics like this then we will never be able “afford” the care we really need.
What bothers me about your story is this–when did anyone (read: nurse) take the time to establish a relationship with this patient and her family? Are nurses now relegated to tasks only? Are we too busy to get to know the patient and her/his family?
Nurses are at the sharp end of healthcare–we’re there to protect and care for the sick, the vulnerable. That care involves more than just administering medications on time, documenting, etc. It involves critical thinking, skilled communication.
If we don’t take the time to get to know our patients, then how can we serve as a patient advocate?
The link below is an interesting paper about how the US healthcare system came to be what it is and how it compares to other countries. It discusses a wide spectrum of alternatives to the current system, open vs closed systems, Medicare and Medicaid, lack of national health care policy, lacking primary health care, determinants of health outcomes, quality and cost-effectiveness of healthcare sevices, and related social and political issues.
https://courses.duke.edu/@@33A7E7D4193C3810B891CCC3E7A8611C/courses/1/NURSING301.02-S2009/content/_1657285_1/Mason%20-%20The%20US%20Health%20Care%20System.pdf
kudos on the new blog and the posting. You’re absolutely right that compassionate end-of-life care needs to be part of the discussion. First and foremost, it saves the patient (and the family) drawn-out pain and suffering, and second, it saves a whole bale o’ money. Sadly (cynically), that may be its biggest selling point.
You’ve hit the nail right on the ball, as I once heard someone say.
Suzanne,
I am so glad you have launched your web site. I would also encourage you to link your blog to our most active social network sites like allnurses.com, nurseconnect.com and nursinglink.com.
You have been an articulate and impassioned champion of nursing for many years – doing a much better job of communicating our value and contributions that we do for ourselves. One example, President Obama’s recent public discussion of the impact of the nursing shortage — he did not invite nurses to participate.
How can we become more effective at building public awareness?
Good on you for raising this issue. Nursing is supposed to be about working ‘with’ our patients/clients towards optimizing their health outcomes, and that includes a peaceful death. So long as the patient wants to go for high intervention, that is one thing, but frank dialogue about options and issues is important and RNs must advocate for the patient’s rights. For many,over half of their cost to the health system comes in the last six months of their lives,often with interventions they do not ever want, nor as pain-free as they would chose, nor in the place they would chose. A surgeon should have to get approval from a committee, with citizen presence, when contemplating high risk with low probability of success before being allowed to make such decisions. Imagine if some of those resources could be reallocated to support individuals to optimize their wellbeing and to assist them to remain in their own homes for as long as possible with optimal supports. Coalitions for elderhealth and eldercare are long overdue.
Suzanne:
You bring up a very difficult but important point with your discussion of futile end-of-life care. And, I think, your point about a competent primary care provider cannot be overstated. I run into this issue daily in the Emergency Department, where people often come expecting a quick diagnosis and definitive treatment. But many times we can only tell the patient what they don’t have …. an emergency condition (“you don’t have appendicitis,” “you aren’t having a heart attack…”) What they do need (and should have started with)is careful follow up with a provider who will see them repeatedly over time, monitor their condition, and make appropriate referrals to specialists. If you don’t have a primary care provider before you come to the ED it is a lousy time to try to find one. It is hard to get timely follow up appointments with PCPs whom you’ve never met. If you are under or uninsured, you probably will not find one. Better availability of competent PCPs and more savvy use of them by the public would reduce expensive overuse of the ED for routine and non-urgent care. And finally, if a serious situation develops, there is someone to help guide the patient and family through the confusing layers of care.
I have had conversations with patients and families were I all but got on my knees to beg for an end to the kind of non-sense you describe in your post on reform in America’s health care system. I have been called arrogant because I refused to wear my heart on my sleeve but rather my brain. I have been called uncaring because while drawing up insulin in a syringe, I did not look at the caregiver while answering her question. I have been fired for insubordination because I advocated for my patient to have a room with her husband, who had alzheimer’s, and was continually told that it could not be done because the husband’s level of dementia was not the same as his wife. I could go on. But suffice to say I am going before the DSHS in Washington state because I had a combative patient take a swing at me, when she missed I put the patient in a bear hug, picked her up and carried her to the stretcher while two EMT’s and a police officer watched. Because of that act I am being charged with abuse and if the charges stand I may never be able to work as a nurse again.
I feel terrible when I hear stories like this. You should contact people like Jane Lipscomb at the University of Maryland School of Nursing to share your story about violence. That’s definitely something that needs to be really considered in nursing and other service areas — this idea that accepting violent or abusive behavior is part of the nurse’s job description. Similarly, I think you hit upon something very important when you talk about people complaining about nurses who are not constantly smiling while they are doing their work. It’s almost as though a look of concentration — a look of vigilance — is uncaring. Concentration is a sign of competence which is the essence of caring.
When my husbands Aunt was 90 she was in the hospital recovering from the flu. He told me they thought she might have breast cancer and wanted to do a biosopy. I said, she is 90 years old. Leave her a lone. Families have to take control.
And seriously my name is Suzanne Gordon, I am in IT though instead of nursing. Though I am on the board of Alliance Medical Ministry in Raleigh, NC. They provide health care for the uninsured working poor.
Great to see you are blogging, we need more strong voices for nursing on the internet speaking loudly.
Education is the key to this problem. I worked in oncology for 10 years so these conversations were commonplace. When the 90 year old get triple bypass and the surgeons want ‘everything done’ I gently inform the very berieved family that they have other options. People don’t realized they can say ‘no more’.
Hi Suzanne,
I enjoyed reading this post. It is very interesting. Our health system is definitely broken. I do not believe socialized medicine will be an answer. I hope Obama does not propose that to be our solution.
Hollye Clardy, RN
The style of writing is quite familiar . Did you write guest posts for other blogs?
nope this is my first blog ever
Love your writing Suzanne. Your blogging, like your international advocacy, opens space for important public discourse associated with issues impacting organized health and illness care today. Thanks be to you for this space!! :-))
With respect to “Health Care Reform – a la Americaine”, a couple things come to mind. As I reflect on your comments and the stories in your post, I can not help but wonder from where the “treat to death” intention – which is ubiquitous in care today – emanates. In my view, the lack of routine primary health care is certainly a contributing factor. Quaternary prevention (on the continuum of primary, secondary, tertiary, quaternary prevention) is beginning to declare itself in the literature. QP is an ethical approach to practice which calls providers to consider the impacts of over medicalizing treatment decisions. QP, should it become a normative part of the assessment process, does not take a long time and is a practice which asks providers to engage the patient in setting negotiated goals of care and advance care plans. In the doing QP reduces vulnerability by empowering the patient; it goes without saying that QP has a strong nursing flavour about it.
This written, given the equally ubiquitous legal advertisements on television and the public’s addiction to insurance company settlements, it is not surprising that many providers’ response to illness care decisions is treat, treat, treat …at all costs.
Patrick: I am so sorry that you have had to endure the labeling. “Arrogant” is an all too common label applied to men in nursing who – in some respects – practice, process and communicate nursing data differently than do our sisters in practice. I too have been beaten with the arrogant stick … “demeaning, uncaring and intimidating” are barbed branches on that stick that extract more than a pound of flesh. Keep your chin up my brother in care. I sure hope that your legal troubles are resolved with the least poundage lost.
This is very perceptive and I really appreciate your post. Please continue to read the blog and offer your views. thanks so much.
Incredible site!
I recently left a job at a premier teaching hospital because a lack of response by some attending
physicians in my requests for palliative care consults for some of my patients with multi-orgtan system failure on triple pressor therapy. A common response is “We are not ready to give up,” or worst yet “I am not ready to do that.” The suggestion that palliative care services establish a trusting, consistent on-going dialogue with the families of critically ill patients and lend comfort at possibly the most distressing time of their lives is not a consideration.
In essence, the families are not made aware of this treatment option until a day or so before death. Is that not witholding treatment options?
“
I recently left a job at a premier teaching hospital because a lack of response by some attending
physicians in my requests for palliative care consults for some of my patients with multi-orgtan system failure on triple pressor therapy. A common response is “We are not ready to give up,” or worst yet “I am not ready to do that.” The suggestion that palliative care services establish a trusting, consistent on-going dialogue with the families of critically ill patients and lend comfort at possibly the most distressing time of their lives is not a consideration.
In essence, the families are not made aware of this treatment option until a day or so before death. Is thisnot witholding treatment options?
“
Donna, thank you for this. It is tragic that you had to leave your job because of this total failure of teamwork. I happen to know that the hospital where you work is interested in patient safety but why isn’t this considered to be a patient safety issue? What it highlights is a total failure in teamwork. It’s clear that the physicians did not include nurses on the team and that their idea of team leadership is that they, not anyone makes decisions. On a real team, these decisions would be made with the input of all involved — most notably the family. How do you think these issues can be raised more forcefully? How has it made you feel to have to leave this job? I’d like to hear more about this.