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Friday, January 13, 2012

Going to Heaven with our Stitches in

A team at the Harvard School of Public Health published a disturbing article in Lancet on "The intensity and variation of surgical care at the end of life."

The group studied the 1.8 million Medicare beneficiaries who died in 2008 to determine the frequency of surgery during the last year of life. 32% had an inpatient surgical procedure during their last year. 18% had surgery during their last month. And 8% had surgery during their last week.

This is a population study, so it doesn't tell us how often the surgery was required by the patients' true needs and wishes. But I'd bet dollars to pennies that most readers of this post have seen surgery done in situations where a better informed patient and family would have rejected the proposal.

My beloved late father-in-law, who I wrote about two days ago, was vigorous until he turned 90, at which time angina limited how far he could walk in New York City's Central Park. Early in his life he'd been in the plumbing supply business, so when a revascularization procedure was proposed to him he thought of it as a common sense plumbing repair. He didn't consult with his family before deciding to do it. The result was five months of intractable heart failure before his death.

He was a gentle, fair-minded man and forgave his physicians for a recommendation they shouldn't have made and he shouldn't have accepted: "My doctors were young men. They were thinking about young hearts, not about 90 year old hearts."

Dr. Ashish Jha, leader of the Medicare study, told a similar story from experience at his own hospital:
A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”
The election year concern is with Medicare costs. But the primary problem for my father-in-law and the patient Dr. Jha describes is care, not cost. Overtreatment is a serious problem for Medicare beneficiaries. More appropriate care for folks like my father-in-law and Dr. Jha's patient would have had the secondary benefit of reducing cost. That's better medicine, not "death panel rationing"!

[This post is a slightly modified version of a post I wrote in October on my  healthcareorganizationalethics blog.]

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