Why is it so hard to die?
December 9th, 2008 by Al Lewis (alewis)A restaurant which insisted on giving us more food than we wanted, and wouldn’t let us leave until we ate it all, and sent the other diners the check for our extra portions, would go out of business within hours.
Yet, that is exactly what happens when it is time to die. In forty-eight states we are not allowed to say, “that’s it, time to leave,” no matter how ill we are. We have to wait for nature to take its course, at taxpayer expense. And that’s the best-case scenario. The worst-case scenario is that we are kept alive against our will because we forgot to complete a form, or completed it but didn’t get two witnesses, or lost it, or the hospital can’t find it.
This life support is financed at the expense of taxpayers or fellow policyholders. In times of economic crisis, one has to reexamine every budget item and eliminate or curtail those which are not cost-effective. Since there is no benefit in keeping people alive against their will, this tradition would be a perfect example of one whose time has passed. While hospice use is increasing, there are three logical next steps to make people better off while saving money.
First, if someone does have an advance directive, make it the hospital’s responsibility both to find it and to adhere to it, and if they do something which is at variance with it, they don’t get paid. Sort of like Medicare does today, not paying hospitals for infections. You will be amazed at how many of these directives will suddenly turn up once incentives are aligned.
Second, life support should not be covered in basic health insurance or Medicare. It should be a rider, like Part B Medicare today. People who think they want to be kept alive when there is no hope of leaving the hospital should simply elect the extra rider. (Of course they could change their mind at every anniversary date.)
Finally and most controversially (like those first two are not controversial), the other 48 states need a physician-assisted suicide law. Before anyone gets shocked at this one, I should tell you from personal experience that there already is hospice nurse-assisted suicide. It’s informal and is done with a wink-and-a-nod and statements like “towards the end you can give him/her as much morphine as you feel appropriate.” I know this from personal experience, having recently lost my wife. However, because it is not legal, it is not handled well by the hospice nurses. Once one’s circulation is impaired it is very cumbersome to die this way, and the nurse of course is not allowed to be more specific. So assisted suicides are readily available, the same way illegal abortions were readily available, and with the same occasionally inhumane results.
I would close with an editorial comment: The hospice nurse, visiting a few days before my wife died, said that she had never seen an ALS patient so well cared-for physically and emotionally. But that was not true the last 24 hours, when her extremely conscientious and well-intentioned sister and I had no idea how much morphine to give and what else to do. However, there should never have been a “last 24 hours,” and I blame the Commonwealth of Massachusetts for that.
*****
Q: Why do coffins have nails?
A: To keep the oncologists out.
December 9th, 2008 at 4:17 pm
Al, I am so sorry to hear about your wife.
Your suggestions, of course, are too reasonable and simple ever to be put in place.
At least I have copies of my parents’ and my wife’s advance directives in a very easy to get to drawer.
Love the joke. We used to say that we had a network oncologist who gave chemo at the funeral home. Gave QO fits.
Best regard, Tim
December 10th, 2008 at 7:09 am
one wonders how adamant Terry Schiavo’s family would have been about keeping her alive if they had been paying the bill instead of the rest of us. Society has an interest in keeping us all healthy. That is why public healthcare exists, but it has no interest in keeping people alive a few more days or weeks. That is a “private good” not a public good like healthcare.
December 10th, 2008 at 8:47 am
Make it even easier — just specify that the form document for the advance directive, which contains checkoff options, have an additional option of physician-assisted suicide, so someone can elect it right on the advance directive. The “rules” for it would be patterned after Oregon.
December 10th, 2008 at 9:46 am
I have been through this personally with my mother. She could not possibly have wanted to die like she did but the most you can do is take someone off life support, which we did and which she wanted. BUt she didn’t die and seemed very uncomfortable. Even speeding it up by 3-4 days via physician-assisted suicide would have been a blessing. And, yes, a cost savings
December 20th, 2008 at 8:39 am
someone could write a book on it - step in where the states are failing - on how to handle the last days of caregiving. An author could say stuff that a nurse couldn’t say
December 27th, 2008 at 7:21 am
I think you could do just the first two and shine a light on “futile care” in the USA. I think we are spending way too much on futile care and that money could be redirected. Those two ideas are easy ways to reduce this amount.
December 31st, 2008 at 9:50 am
The issues here are like the value issues in the abortion debate. However, they really are different. There is much more pain and suffering and futility in the death process. The argument that uses Thou shalt not kill” is horse manure. Even the scripture identifies exceptions some of which are as difficult and more questionable than turning of the respirator (like war, the death penalty for certain crimes, and self defense). Rabbinic Midrash (teaching) is great on this. Ethical principles are often the clash of several values. There is clearly a point where it is more cruel and unjust to prolong the life.
January 1st, 2009 at 9:38 am
Barry raises a good point. Abortion is about the life of the fetus. One must respect that both sides of the debate have deep passions about it even if in complete disagreement. Here, though, we aren’t talking about someone’s life. We’re talking about extending the death process for a few more days or weeks. And I have no objection if peopel wwant to do that . I just don’t want to pay for it. It has nothing to do with health care and shouldn’t be in the basic policy I buy unless I want it separately.
January 2nd, 2009 at 9:39 am
your blog raises the economic issues squarely. I Your make a supposition in your recommendations that changing the economics or reimbursement would change the provision of services. However, the sensitivity of the issues in my earlier email make adoption of policy and social acceptance difficult.
January 27th, 2009 at 10:37 pm
Just because something takes place in a healhcare setting, doesn’t make it healthcare. Staying alive is a religious decision and shoukd not be subsidized by the government. Botox, though not a religious decision, takes place in a healthcare setting but it’s also a matter of personal choice, not a matter of healthcare. I vote for the ‘controversial” option
December 5th, 2009 at 3:17 pm
The nurse at the nursing home notes the decubitus ulcer on the patient’s lower leg. The patient has something wrong with every organ system, is bedridden and on tube feedings, has not had a thought in years, and has contractures in all muscle groups. The nurse is obligated to call the PA who makes rounds every day. The PA feels obligated to tell the internist who makes rounds every month. The internist decides that her only hope is amputation and feels obligated to call the surgeon. The surgeon was obligated to see what the family wanted done. The family, who lives 500 miles away, says, “do what you can.”
I was in the OR when the surgeon was holding the leg and joked, “It’s pretty sad when you get off the specimon and can’t decide which part to throw away.”
DB