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.]

Raising the Age of Medicare Eligibility - First Prize Dumb Idea

This week the Congressional Budget Office released a report on proposals to raise the age of eligibility for Medicare and Social Security.

The CBO concludes that raising Medicare eligibility to 67 would reduce federal spending by $148 billion between 2012 through 2021. By 2030, Medicare's net spending would be reduced by 5% - 4.7% of GDP rather than 5%. Those numbers sound good.

But reducing federal expenditures doesn't reduce the need for medical care. Some lucky folks (I'm in that category) (a) have employment that provides health insurance and (b) are happy to continue working. Some who would rather retire will continue to work, increasing health care costs for their employer (and fellow employees). Some will scramble to find alternatives which will cost them more than Medicare would. And some will become uninsured, at an age when this is progressively risky. Overall costs - to individuals, employers and other government programs would probably go up more than the $148 billion reduction in Medicare outlays.

The CBO does not comment on the fact that employers are not clamoring for ready-to-retire employees to stay on the job simply to avoid being uninsured.

Raising the Medicare eligibility age isn't meaningful cost reduction - it's simply a form of hot potato, dumping the costs into other accounts. It intensifies the fragmentation of our health system, and worsens overall quality of care.

In my view, the proposal is born out of despair about achieving constructive Medicare reform in which health professionals, patients and families collaborate on behalf of improved care (basically more compassion and less technology) and reduced costs. From 35 years of practice in a not-for-profit HMO setting I know this kind of collaboration is possible. But it requires a spirit of cooperation and trust that is not easy to find in our toxic political environment. 

When Will We Die?

The most recent issue of the Journal of the American Medical  Association has an important article, with an accompanying editorial, on the effort to predict life expectancy for patients over 60.

My armchair research (conversation with friends) suggests that our Medicare cohort has two antithetical fears about longevity and medical treatment. Some fear we'll be flogged with aggressive interventions way beyond the point of usefulness. Others fear we'll be consigned to the grave too quickly, and even if not actually buried alive, won't be offered interventions that could reasonably be expected to provide significant quality of life.

I'm on a week's holiday in Puerto Rico. This morning another guest was playing good tennis on the adjacent court. When we chatted later he told me he'd had a total knee replacement two years ago. He enjoys skiing and tennis. He's experienced impressive improvement in the quality of his life.

In contrast, 13 years ago my beloved father-in-law, 90 at the time, experienced angina that limited his walking. His physicians recommended a surgical revascularization procedure. He was an activist, and without telling anyone in the family until the night before he went into the hospital, scheduled the surgery. The results were catastrophic - an extended period of delirium and progressive heart failure. He declined rapidly and died after a few miserable months. Poignantly, his oldest grandson's best friend is a distinguished cardiovascular epidemiologist. Had he been consulted, he would have given a strongly evidence-based recommendation against the procedure.

My father-in-law was a thoughtful, forgiving man. He said  "my doctors were young men [i.e., in their 50s]. They were thinking about young hearts, not about 90 year old hearts."

The article identified 16 systems of prediction that show reasonable accuracy, but none were good enough to be recommended for routine use in practice. The editorial urges physicians to (a) consult readily available life tables (predicted longevity by age, race and gender) and then (b) consider individual factors. Here's the relevant passage:

These calculations could be facilitated through use of an electronic comorbidity and functional status. Lung disease requiring regular use of corticosteroids or supplemental oxygen, New York Heart Association class III or IV congestive heart failure, renal disease requiring dialysis, advanced dementia, inability to walk more than a block, and need for personal assistance with bathing are examples of factors that would reduce life expectancy substantially below the average. The absence of significant comorbid conditions or functional limitations would identify older persons who are likely to live longer than average.

As a starting point, age-, sex-, and race-specific life expectancies (median and interquartile range) can be calculated using data from standard life tables.

The authors have created a remarkable website - ePrognosis - that allows health professionals (identified by self report) to apply relevant tables to their patients. They've also created GeriPal (GERIatrics and PALiative care), a blog for health professionals and others interested in care of the elderly and palliative care. I'm proud that one of the sponsors - Dr. Alex Smith - did his primary care residency in the program I teach in. ( He was a star!)

Conversations based on life tables, individual status, and the patient's guiding values, won't achieve mathematical certainty. But they're crucial elements of wise, compassionate health care decision-making. It was monstrous when politicians branded support for this form of humane medical practice "death panels." We Medicare folks need to fight that form of demagoguery!

An Attack Ad in New Hampshire

Have a look at this TV advertisement attacking NH Representative Charlie Bass for his support of Paul Ryan's Medicare voucher program.

I'd never heard of Representative Bass until the ad came to my attention. The Wickipedia blurb about him suggests that on some issues (abortion rights, environment) he's relatively progressive for a Republican, though he follows party line on the Patient Protection and Affordable Care Act & voted for its repeal.

I have mixed feelings about the ad. I'd like to see Republicans lose their majority in the House. But although I think Paul Ryan's voucher plan is deeply flawed, I think it should be a discussable policy alternative.

The ad reinforces the widely held view of Medicare as a "third rail" of politics. And no matter where we are on the political spectrum, a healthy future - for Medicare and for the U.S. economy - requires opportunity to deal thoughtfully with the need to improve the program and constrain its costs!

Harmful Hospital Errors are Vastly Underreported

In an article by the always informative Robert Pear in yesterday's New York Times we learn that a just-released study from the Inspector General of the Department of Health and Human Services reports that only one in seven errors, accidents, or other events that harm hospitalized Medicare beneficiaries gets recognized and reported. (As of today, the report itself isn't available on line.)


Quality improvement gurus teach that "every defect is a treasure." Sometimes recognizing that avoidable harm has occurred lets us help the involved patient, but there are always important lessons that can prevent repetition and help other patients in the future.


The unreported events were identified from detailed study of hospital records. They included

medication errors, severe bedsores, hospital-acquired infections, delerium from overmedication, and excessive bleeding linked to improper use anticoagulants. The Inspector General calculated that more than 130,000 Medicare beneficiaries experience this kind of injury each month!

What I found most disturbing is the Inspector General's surmise that the primary reasons for the underreporting were (a) not recognizing that avoidable harm had occurred or (b) seeing the incident as so common that it didn't need to be reported.

"Developing a culture of safety" is a common mantra, but we clearly have a long way to go to make it more than an empty cliche.

Fidelity and Stewardship as the Guiding Values for Medicare

I've used this diagram for many years in teaching about the ethics of health care provided to a population within a budget - HMOs, ACOs, VA, public sector mental health, and countries that provide universal coverage. Given the absurdly fragmented system we have in the U.S., it's difficult for patients, physicians and the public to have a sense of the denominator we're part of (the population served under a budget).

I believe the diagram shows the right ethical perspective on Medicare. We want attention to the needs of the individual to predominate in the exam room, but not to the total exclusion of awareness of our responsibilities to others as well as to ourselves. We want attention to the needs of the population to predominate at the policy level, but not to the total exclusion of awareness of the implications of policy decisions on individuals.

Ability to embrace complexity is part of maturity. I'm convinced that if we were able to survey the Medicare population, a large majority would embrace the moral perspective shown in the diagram. Wider endorsement of fidelity to the needs of the individual AND stewardship of shared resources on behalf of the population will provide the ethical basis for doing what we need to do to make Medicare secure for the future.

My aim for this new blog is to encourage my fellow members of the Medicare community to give stronger voice to fidelity AND stewardship as the proper guiding values for Medicare reform.

Two Common Sources of Overtreatment

Experts, most recently former CMS administrator Don Berwick, tell us that 20% - 30% of medical care is "waste." At the very least, "waste" is harmful to all those who pay for Medicare. But often it's directly harmful to the patient as well.

I recently saw a friend at a holiday party. Since we'd last seen each other my friend's spouse had died. (I'm deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care with problem-ridden hospital care. Here are two examples of "waste" that were thwarted only by my friend's vigilance.

My friend's spouse ("the patient") was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a "picc line" ("picc" = "peripherally inserted central catheter").

On returning to the patient's bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded - "I don't have it."

My friend replied - "Rather than putting such a sick person through another CT and spending another few thousand dollars, let's get it."

With regard to insertion of the catheter, my friend asked: "what aspect of the plan does it serve?" The answer was - it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the picc line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn't the right way to get it. And having routines can promote patient safety - but only when the routine is tailored to the true situation. In a non-emergency, clarity about the treatment goals of patient and family should be part of the what we routinely expect of ourselves.