Friday, August 6, 2010

Hospices and Healthcare

Healthcare is sure to figure prominently in the fall elections as Republicans run against "Obamacare." Many candidates might revive last summer's charges of death panels and "pulling the plug" on grandma. That is partially why I found this article so interesting in the New Yorker. It asks us a much-needed and under-discussed question. At what point should we focus on comfort care instead of keeping patients alive as long as possible?

It is likely that steering patients with terminal illnesses to end-of-life care instead of intensive care would save a good deal of money. With Medicare and Medicaid costs consuming a large portion of the budget, expect discussions of how much we should fund intensive care to proliferate. And this will put politicians of all stripes in a tough situation. Conservatives are planning to use the budget deficit as an issue in their fall campaign for Congress. Furthermore, they want to cut the deficit sharply by reducing spending, not by increasing taxes. The real meat of the budget are programs like Medicare as I said earlier. It won't be enough just to cut food stamps and pell grants. And hawks will be loath to cut defense, so by process of elimination, they'll have to make some meaningful cuts to Medicare. So if conservatives are to match their rhetoric, they will have to contemplate cost-saving measures such as promoting end-of-life care. Ironically, they could have to promote the very "death panels" they decried last summer. Should they find that unappetizing, they will have to do something drastic like means-test the program so upper-middle class and the middle class elderly no longer qualify for benefits. Imagine the howls of protest that move would bring from senior citizens, who vote in large numbers. Either way, they lose.

Liberals who want to keep the Bush tax cuts for families making less than $250,000 a year won't have enough revenue to pay for their priorities and will be in a similar position. They will also have to keep answering an important question: how extensive should a government's role be in promoting the welfare of its citizens? It is said that Americans oppose any attempt to ration healthcare to the elderly because they wouldn't want to see their own grandmother denied care. But when faced with paying higher taxes that liberals support because they're reluctant to cut entitlement spending, we'll find out how much Americans are willing to pay to help someone else's grandmother.

The more interesting dimension here is ethical. As a doctor or family member dealing with a patient or loved one who has an incurable illness, what's the right thing to do? On one hand, life is precious and we want to make the most out of it that we can. We would never want to condemn anyone to death when they have a chance at life. But at some point, that instinct must be weighed against the pain that a drawn-out process of treatment would cause the patient. Interestingly, there is little difference in the amount of time people live who choose hospice care, and the amount people who choose intensive care live. In fact, those opting for hospice care live longer in some cases according to the previously cited New Yorker article.

As a family member, one has to ask why he or she urges heroic, life-saving measures for a patient. Is it because he or she can't bear the thought of living without the loved one? Or is truly to protect the best interests of a patient. These are gut-wrenching questions. Questions I pray I never have to ask myself.