Prepare the Ice Floes

The New York Times reports on the next great cost saving measure in the US:

Medicare, the federal program that insures 55 million older and disabled Americans, announced plans on Wednesday to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.

Time to prepare the ice floes for Grandma before global warming forces us to use more expensive methods…

Or this is a simple, minor technocratic fix that enables people to make more fully informed decisions about their lives, their families and their expectations while they are not under pressure of contradictory information and values?

We know a few things about death.  It happens to everyone.  The months immediately preceding death are statistically the most expensive time on average, we tend to overtreat and over-intervene at a heroic basis before death even as the person being intervened on does not want heroic treatment.  Death and the possibility of heroic intervention to avert death can and will tear apart families.

Talking about death is important, and that means paying for providers to talk about death.

Wisconsin has had some success in getting people to think about how they want to die:

Imagine a town of 50,000 Americans where 96% of those who die have signed an “advance directive” codifying their conscious decisions about how they would like to die. This is quite an accomplishment given we haven’t been able to move the needle at a national level beyond 30% over the past 30 years….In La Crosse the simpler, cheaper and more accessible innovation that was good enough to get the job done was the ancient art of conversation. Hmmmm. Talk maybe cheap… but effective….By 1995, 85 percent of people that died in La Crosse County had an advance directive and by 2009 the number had reached 96 percent–more than three times higher than the national average. Nationally, the average cost for a patient’s last two years of life is $26,000 (in some hospitals average costs run as high as $65,000) the average cost in La Crosse, is just $18,159. More importantly, knowing patients’ wishes ahead of time ensures the best possible care and relieves debilitating emotional and financial stress for families. Family members don’t have to debate about what their loved one would want for treatment and avoiding decisions made in the spur of the moment.

 

 

81 replies
  1. 1
    WereBear says:

    Family members don’t have to debate about what their loved one would want for treatment and avoiding decisions made in the spur of the moment.

    A million times yes. The situation with my husband’s grandmother was helped by the fact that she had stated her wishes, vehemently and often, but it would have been still better for her to have actually signed the thing she filled out…

    Apparently it happens a lot. Check.

  2. 2
    Origuy says:

    My housemate spent most of the last 10 months in and out of hospitals, after a spinal fusion that had multiple complications. Every time she was admitted, she was asked if she had filed an advance directive. It’s not a great time to have to think about it.

  3. 3
    JPL says:

    @WereBear: To me, it’s a win situation because some family is too close to the situation. I have a directive in place already along with my will. I also have a son, who would be happy with me joining Ted Williams, so it was necessary for me to have legal documents.

  4. 4
    Matt McIrvin says:

    This is so necessary and at the same time such a political third rail.

    Still, maybe it’s not a political loser forever. I recall it was the Terry Schiavo situation that finally convinced John to jump ship from the Republicans.

  5. 5

    @Origuy:

    Every time she was admitted, she was asked if she had filed an advance directive. It’s not a great time to have to think about it.

    I assume this is more about the hospital wanting to know about the advance directive so they know what to do than it is about trying to bully her into getting one.

  6. 6
    KG says:

    Cue the “DEATH PANELZ!11!!1!” screaming in 3… 2… 1…

  7. 7
    Eric U. says:

    I hope we get this sorted out for my kid’s sake. It was torture with my dad. I suppose it wasn’t clear to us that they figured he was going to die, but it seemed like they would ask us if they did everything more invasive than feeding.

  8. 8
    jeffreyw says:

    I’m so old that there may actually be enough ice floes remaining.

  9. 9
    raven says:

    @jeffreyw: Sheet bubba, you just getting started!

  10. 10
    Cervantes says:

    the next great cost saving measure in the US

    While it can cut costs, it can have other benefits, too.

  11. 11
    Origuy says:

    @Roger Moore: I don’t think the hospitals were bullying her. It needed to be done and she eventually did it. My point was just that it should have been done before. And now that I say that, I haven’t done one either.

  12. 12
    Bobby B. says:

    @jeffreyw: Would you be averse to being beaten to death with 10-pound ice bags? The glaciers aren’t gone, they’re just resting in an undisclosed location.

  13. 13
    raven says:

    @Origuy: We finally did wills and AD’s in the spring. The dude says, “ok, that’s great now we can redo it in 5 years”!

  14. 14
    Cervantes says:

    @Bobby B.:

    Would you be averse to being beaten to death with 10-pound ice bags?

    Soon that may be a positive end.

    Given climate trends.

  15. 15
    peach flavored shampoo says:

    DEAF PANULZ, YO!

  16. 16
    Brachiator says:

    Talking about death is important, and that means paying for providers to talk about death.

    Be careful what you wish for. I agree that this is valuable, important stuff. But the precedent will also be used to justify increasingly invasive and delaying actions to dissuade or prevent women from having abortions.

    But back to the main thrust of the topic, how is this handled currently in states with comprehensive programs related to this (Oregon, maybe?) and in other countries?

  17. 17
    alce_e _ ardilla says:

    Have the tags become self aware and self-replicating?

  18. 18
    japa21 says:

    It is about time Medicare started doing this. Keep in mind, many doctors have already been having these discussions with patients, they just haven’t been reimbursed by Medicare for their time. And as the situation in LaCrosse shows, the amount of money spent on paying for these consultations results in a high return on investment (that shouldn’t even need to be considered).

    I am sure some actuarial minded person could figure out the total savings to Medicare over, say, a 10 year period, but I would imagine it could easily hit a billion dollars or more.

    And, as others have pointed out, the extent of savings in emotional anguish is also high. I don’t remember if my mother had an advanced directive, but she made it very clear that she would not accept drastic measures. And all 6 kids went along with her decision. I actually think the grandkids had a harder time of it.

  19. 19
    WereBear says:

    I think the more neuroses a family member has about mortality, the worse their decision making on this point becomes. Worse yet, it becomes about them, not about the sick person’s wishes.

    Ironically, the more fundamentalist Christian sects have a terrible rep among medical personnel. For all their lip service to the glories of the great Beyond, they act terrified of going there.

  20. 20

    @WereBear:

    For all their lip service to the glories of the great Beyond, they act terrified of going there.

    Guilty consciences.

  21. 21
  22. 22
    jeffreyw says:

    @Bobby B.: I once pondered climbing into a hotel ice ice bin while on the road working an out of state job. Turns out I was too drunk to manage entry and that probably saved me from a Darwin award.

  23. 23
    J R in WV says:

    My grandfather had little strokes, that affected his memory to a degree. We were pretty young at the time, and grew to adulthood while granddad was in a hospital room, with no memories at all, and not much personality either. He was gone, really, even though he was awake and would chew and swallow food. There was never a sign that he knew who we were when we visited.

    There was never any serious treatment after the few days after his last stroke, just care and feeding. He did show appreciation of ice cream, it was the only time he smiled.

    Finally the old hospital he was in for those many years was replaced with a new one, and when they moved him across town he came down with pneumonia. No one was willing to authorize any treatment, and he finally died after 8 or 9 years in the hospital.

    So our family has a united attitude for drastic measures. No. Just don’t. My wife and I have signed directives to that effect. I signed mine as I was preped for shoulder surgery, and an OR nurse was witness, which is leaving it a little late, but whatever.

    I’m tempted to have a DNR tatooed on my chest, as I know some medical staff have.

    My grandmother was 92 when she had a bowel blockage. They operated, and found that it was from a blood clot which had killed off a section of her bowel. So they did what they could. It didn’t work out so well, as she was so fragile.

    We had a hell of a time keeping the surgeon from working on her again every day. in fact my aunt, her oldest child, visited the hospital management with a lawyer to make sure they understood the families’ orders with regard to the surgeon – he was not to touch her or participate in her care in any way other than to stand beside her and visit. Which he never did once we ordered him not to treat her. He was a terrible human being, regardless of his advanced medical/surgical skills, because he had no empathy. There should be a test for that before you can get into med school.

  24. 24
    WereBear says:

    @Amir Khalid: Thanks, I love that song.

  25. 25

    @J R in WV:

    He was a terrible human being, regardless of his advanced medical/surgical skills, because he had no empathy. There should be a test for that before you can get into med school.

    If you have a test for empathy as a condition for getting into med school, we’re going to have a terrible shortage of surgeons. Empathy can actually be a disadvantage when your job is cutting people open and messing around with their insides.

  26. 26
    Goblue72 says:

    Somebody needs to ask Hillary about Deathghazi.

  27. 27
    burnspbesq says:

    @Goblue72:

    Somebody needs to ask Hillary about Deathghazi

    Those e-mails sleep with the fishes, right next to Lois Lerner’s.

  28. 28
    Brachiator says:

    @J R in WV:

    . He was a terrible human being, regardless of his advanced medical/surgical skills, because he had no empathy. There should be a test for that before you can get into med school.

    It’s sad to hear what you went through with your family members.

    Hopefully some of these discussions and changes in practice will help everyone who has to go through these situations.

  29. 29
    Spinoza Is My Co-pilot says:

    @alce_e _ ardilla:

    Have the tags become self aware and self-replicating?

    I was wondering the same thing…

  30. 30
    EconWatcher says:

    @J R in WV:

    Very sorry for your experience. It seems that surgeons very often lack empathy–the brain surgeon for my dad sure did–but he was also one of the best ranked in the world. I do wonder if having to look at the human body as a structure that you must cut and manipulate breeds a lack of empathy, or maybe even requires it.

  31. 31
    Gindy51 says:

    @J R in WV: Most surgeons do not have a ton of empathy, at least the ones I’ve been in contact with. They’d be serial killers if they weren’t doctors. I think a certain mind set is needed to be able to cut up live human being, even if they are knocked out six ways to Sunday.
    The same thing happened to my MIL, colon surgery for cancer, wound never healed, dead within 3 months. I warned them not to let it happen but her kids don’t have the heavy duty disdain that I have for the medical community (dead parents from medical mistakes will do that to you every time). I was right, again, and she did not have a very nice last 3 months with a gaping sore and all that that entails. She was a shit human being to all her kids’ spouses but no one deserves that except Dick Cheney.

  32. 32
    Wag says:

    @J R in WV:

    By “treat” I assume that you mean “cut upon”. One of my pet peeves as a physician is the perception that shifting to comfort care means that the patient is given no care. This is absolutely false. Hospice care is a gift that allows the patient and family time to say goodbye with an emphasis placed on comfort and love. If that doesn’t meet the criteria for care, I don’t know what does.

    Luckily surgeons like your family member had are encountered less and less frequently.

  33. 33
    peach flavored shampoo says:

    @jeffreyw: Annnnnnnnnnnnnnnnnnnnnd you just made me think thrice before I grab some cubes from the hotel ice machine. Maybe I’ll just drink all my shit warm.

  34. 34
    Three-nineteen says:

    I don’t have to worry about this with my parents – I’ve got copies of their DNR and power of attorney paperwork. Unfortuantely, I’m not as lucky with my 16 year old cat. It’s been 6 weeks and the vets still can’t figure out what’s wrong. They keep telling me she’s not in a lot of pain and if they can fix whatever it is she could still have a couple of good years left, but she’s obviously miserable and I’m not sure how I’ll be able to tell when it’s time to stop.

  35. 35
    J R in WV says:

    @EconWatcher:

    Well, there may be different types of empathy, but this guy in Columbus was out of control. When the patient’s daughter needs to get a lawyer to meet with management, as opposed to just telling the doctor hands off… crazed egoist. I’m sure some doctors do better without empathy of some sort.

    But a good friend’s son became a surgeon, and he has enough empathy for anyone. When Mrs J was in ICU I would hold on to her and talk to her, loudly since she was in a coma. He was in the hall to meet with other doctors and a patient about a planned surgery, and heard me talking, asked “does that guy look like so and so?” and then came in.

    We had a great talk, he offered to help out in any way he could, was supportive as he could be. His dad is a retired science teacher and activist we’ve known for 30 years or more. The picture of a doctor with empathy…

    Everyone needs this kind of advice and to do the paperwork way ahead of any need. It should be a requirement for something common, like getting SS benefits or retiring, or turning 50… something, anyway.

  36. 36
    Brachiator says:

    Some years back, a radio talk show host talked with his brother, a doctor, about end of life issues. I was surprised that the doctor wasn’t just 100 percent behind living wills, etc. I found another discussion where he talks about this stuff, especially the issue of living wills. Might be useful.

    I think, as Stephan said, yes, it’s true that everybody would like to die peacefully, but the question is, when is it time to die? There’s always the hope that something else may be done that may help the patient, so we don’t know exactly when we’ve crossed the line between prolonging dying and prolonging life. That’s number one. Number two, I think that there is still a problem with people elucidating their desires. People still have a lot of hang-ups about thinking about their own death; they have a fuzzy idea that they don’t want to be a vegetable on a respirator. It’s not very helpful, though, to physicians when they’re dealing with complicated issues at the end of life….

    I also think that we as a society expect too much of living wills. I often challenge physicians who know all about these issues. I say, “Sit down and write me out a living will of precisely what you do and don’t want done for you at the end of your life.” And it’s a lot more difficult than you think. You get involved in details, you get involved in all sorts of permutations and combinations. It’s extremely difficult, even for the initiated, even for the physicians to be able to consider what every conceivable situation will be and what I do or don’t want. I’ve almost come to the point where I think that the best thing is for an individual to pick out a health-care proxy who they trust, have general discussions with that person about the sorts of things they do and don’t want done, and leave the details up to the proxy.

    http://fathom.lib.uchicago.edu/2/10701024/

  37. 37
    low-tech cyclist says:

    Can we put Sarah Palin on an ice floe while we’ve still got some to put her on?

  38. 38
    J R in WV says:

    @Wag:

    My Dad had hospice care as he neared end-of-life. The nurse was an angle of mercy. The doctor was a religious muslim who talked with us frankly. “You have multiple fatal diseases, Mr J, and all we can do at this point is to help with your comfort…” We knew Dad had fatal diseases, and all we wanted was for him to be comfortable and not suffer needlessly.

    That’s what happened.

    Good hospice care is a god-send for everyone who needs it. I can’t say enough about this particular hospice group and the medical staff they had. Empathy and caring was all around. I was able to sit with Dad, hold his hand. It was (American style) football season, and I just left the sound off and the tube on and had a book in one hand and Dad’s hand in the other.

    Best possible outcome for a guy who had been fighting leukemia and COPD for years.

    By the way, as my brother and I worked through the yellow pages looking for a fair price on cremation services, we got price quotes from $800 to over $12,000 for the same thing. So don’t just call and accept the first offer you get! You can get robbed at the moment of grief, which is a whole other thing from empathy!!

    Free advice, worth every penny!

  39. 39
    PhoenixRising says:

    I think the best, most ‘my mom’ moment so far in the 13 days since she was diagnosed w/pancreatic cancer was the meeting with the medical oncologist…in which my mom, who at 72 has lost a husband (’96), brother (’10), and gentleman caller (’11) to upper GI cancers, made the kid doctor tear up.

    “I understand that you can’t code this as a consult for anything except telling me how the drugs you prescribe might extend my life, but we need to talk about what kind of life you can extend and whether I want it. So bill it as a chemo pre-flight, and tell me the truth about just how bad the drugs will make me feel in exchange for how many more days. If you don’t know, maybe you can ask for support from a more experienced doctor.”

    Surgery is in a week. Staging to follow. She’s not buying the bullshit that keeping her alive in a hospital unable to do things is extending her life, so I’m hopeful that she gets the kind of death she wants.

    It is a public policy crime that she has to be willing to fight the world famous facility treating her second kind of cancer to get that small comfort.

  40. 40
    gogol's wife says:

    @Brachiator:

    I think that is very wise advice.

  41. 41
    boatboy_srq says:

    I have to wonder whether all the Death Panels whinging from the conservatists is merely because the discussions are being proposed with medical professionals (paid by Medicare) instead of attorneys (paid by the clients). There are some fairly hefty legal fees that will never get assessed with this change.

  42. 42
    Lurking Canadian says:

    Nationally, the average cost for a patient’s last two years of life is $26,000 (in some hospitals average costs run as high as $65,000)

    Obviously, everything I know about healthcare in the US I learned from a blog post, so I may be completely wrong, but do these numbers not strike anybody else as astonishingly low? Based on the anecdata I read here, I was under the impression that it costs $5000 to set a kid’s broken wrist and $25000 to take out somebody’s appendix. I would have guessed the costs of terminal illness (anything except “hit by bus”) to be in the range of $100K per patient.

  43. 43
    boatboy_srq says:

    @Brachiator:

    I’ve almost come to the point where I think that the best thing is for an individual to pick out a health-care proxy who they trust, have general discussions with that person about the sorts of things they do and don’t want done, and leave the details up to the proxy.

    Just a thought here: pre-Obergefell, heterosexual couples generally used “spouse” to describe their default healthcare proxy; same-sex couples actually had to identify their SO specifically, clearly, and frequently using multiple legal documents, to obtain the same benefit that married couples were afforded without contest.

  44. 44
    Keith says:

    Very recently there was a piece on NPR which examined the behavioral bias of Doctors toward their own end-of-life scenarios.

    The story built from a singular anecdote – an observation by one doctor that a colleague had recently died at home. Sad though this was it prompted the doctor to ask if his colleagues recalled if any of their past or current peers elected to die in hospital. Overwhelmingly, the answer came back – No.

    You might pithily conclude that hospitals are a place even the medical profession would not be caught dead in.

    A kinder conclusion is that doctors collectively recognize the (general) futility of painful though heroic interventions and wish for none of that to be inflicted on themselves. Now, with the opportunity to talk rationally about the choices that might be made with their patients, these doctors can guide an often fearful clientele to a similar gentler, humane dispatch.

  45. 45
    boatboy_srq says:

    @Roger Moore: I’d also suspect it was about finding out what was in the AD so they could contest it more effectively with next of kin. You’d (probably) be surprised how often ER/ICU medical staff try to disregard their patients’ wishes if a family member wants them to get more “care” (read: extenuating, expensive life-preserving treatment for which the hospital can bill an insurer) than the patients desire.

  46. 46

    @WereBear:

    Catholic hospitals are notoriously bad about following DNR orders. They seem to feel that anything short of heroic intervention at all times is morally the same as euthanasia.

  47. 47
    Another Holocene Human says:

    @boatboy_srq: Yup. I was able to hire a gay attorney referred through the community who didn’t charge us too much for all that.

    But despite that, because of the laws in our state the hospital could still decide to just ignore all of that and bar my spouse from my hospital room and vice versa. We got lucky because we knew of couples in our area who had exactly that happen (and unwanted, interfering parents being granted access in defiance of the patient’s wishes).

  48. 48
    Another Holocene Human says:

    @Mnemosyne (iPhone): It’s a contravention of their doctrines about life and death. I think the Council of American Bishops, which has become very politically conservative, went that route in opposition to euthanasia. Just disgusting.

  49. 49
    Another Holocene Human says:

    @boatboy_srq: I thought lawyers tended to be Democrats (except prosecutors, fa fa!) or is that only certain types of lawyers?

    Injury lawyers around here seem to be the Dem counterweight to car stealership owners for the R’s.

  50. 50

    @boatboy_srq:

    I think that on the part of the actual doctors and nurses on the scene, a lot of it is a reluctance to face the fact that they “failed” and the patient died. Even if it was an elderly patient with two kinds of cancer and COPD, the medical staff don’t want to feel like they gave up too soon and that one more intervention could somehow have saved the patient.

    I think medical schools and nursing schools have been trying to teach a more realistic way of viewing terminal patients, but it still happens that doctors and/or nurses can take it as a personal failure if any patient — even a terminally ill one — dies while in their care.

  51. 51
    Brachiator says:

    @boatboy_srq:

    Just a thought here: pre-Obergefell, heterosexual couples generally used “spouse” to describe their default healthcare proxy; same-sex couples actually had to identify their SO specifically, clearly, and frequently using multiple legal documents, to obtain the same benefit that married couples were afforded without contest.

    Certainly, with same sex marriage now recognized, the spouse should be on steadier ground. But some folks are single, and the spouse might not be emotionally able to serve as a good proxy. Or other family members or children might pressure for some other decision.

    The main thing, I guess, is to try to be clear who will be responsible for making the final decisions, even if advice is coming from all over the place, and that this might be preferable to just having a living will.

    ETA: And I am hoping that the Court decision makes it clear that the spouse has a right to be present and in on the decision.

  52. 52
    WereBear says:

    @Mnemosyne (iPhone): Good point. As a woman, I have many reasons to avoid them. As a person, I have even more.

  53. 53
    boatboy_srq says:

    @Another Holocene Human: I had friends go through that when one got sick: the POA was in place, and the Healthcare Surrogacy – but (get this) it all fell apart because they didn’t realize they needed a designated authority for the mortician/coroner/whatever. So up until the one passed, things went as well as you’d expect in a Red State (with just the two of them making decisions), and then parents and siblings got involved and the surviving one got basically told to just p!ss off. One of my pro-SSM arguments was “exactly how many documents does it take to achieve the same respect and accommodation conveyed with a marriage license?” – because there always seemed to be (at least) one that got forgotten.

  54. 54
    boatboy_srq says:

    @Brachiator: No argument. My point was that LGBT couples prior to that decision were treated as two single individuals instead of a couple – and that the hoops to be jumped through to provide for equivalent consideration were many and significant. So post-Obergefell the process is considerably simplified for a meaningful portion of US citizenry.

  55. 55

    @Brachiator:

    Most lawyers want you to fill out a durable power of attorney along with the living will so it’s clear who’s allowed to make medical decisions if you’re incapacitated. When my brother died recently, he had signed POA over to my mom so they could bypass his estranged wife. (They had been legally separated for almost 3 years but the divorce had not gone through.)

  56. 56
    J R in WV says:

    @PhoenixRising:

    Best of luck to you and your mom. That’s a grim diagnosis. She sounds like a no-bs kind of person, and her doctors will probably respond in kind. She’ll make ’em!

    Again, I hope it goes as well as possible for you all.

    ETA: Hospice is a miracle, and can care for your mom in her home! Or yours!

  57. 57
    opiejeanne says:

    @J R in WV: that sounds like the surgeon we dealt with after Mom fell and hit her head, and had a hemorrhage in her brain that was masked for 24 hours by a shunt she had in her head for a cyst she was born with. The shunt drained the excess fluid until it was overwhelmed.
    The surgeon wanted operate right away, said she’d die if we didn’t. I asked what would happen if he did operate, and he said she might live but would pretty much be a vegetable. She had an AD, we consulted it and it contained the magic words: no heroic measures.
    We asked and the surgeon confirmed that the surgery was definitely a heroic measure.
    We decided not to let him operate and he nearly threw a tantrum. Some of the nurses and most of the other doctors involved expressed dismay that we were just going to let her die. The hospice workers, however, and Mom’s own GP were on our side and we had her moved and made comfortable for the last two weeks.

    It was bad enough dealing with these people with an Advance Directive, that I can’t imagine how much worse it would have been without one. Not to mention dealing with my hysterical sister. The AD helped keep her sane, kept all of us sane.

  58. 58
    J R in WV says:

    @opiejeanne:

    Opie, maybe he was regretting the heroic payment he would receive to “save” your mom’s life?

    Gransma’s surgeon at Methodist Hospital was all ego, but some of them really do see every patient as a Beemer payment. I hope you all had help from Hospice and that they were able to provide you mom comfort at her end. Sorry you sister went off a little, that happens. I feel glad that my whole family learned from granddad’s experience, sometimes not doing anything is the best thing to do.

  59. 59
    WereBear says:

    @opiejeanne: The surgeon wanted operate right away, said she’d die if we didn’t. I asked what would happen if he did operate, and he said she might live but would pretty much be a vegetable. She had an AD, we consulted it and it contained the magic words: no heroic measures.

    What a terrible dilemma, but of course you did what your mother would have wanted.

    I think some people get caught up in the fantasy of the one in a zillion chance it will all be fixed and their loved one would get a miracle cure.

  60. 60
    Cervantes says:

    @low-tech cyclist:

    A waste of a perfectly good ice floe.

  61. 61
    boatboy_srq says:

    @WereBear: Patients and next of kin get caught up in that. Providers all too often get caught up in either how Medical Procedure X will benefit the hospital’s billing, or how NOT administering Medical Procedure X will yield a malpractice suit from the patient/next-of-kin who think Procedure X equals Miraculous Recovery.

  62. 62
    Spinoza Is My Co-pilot says:

    Did ADs with both my dad and my dear father-in-law right after each of them were diagnosed with the cancers that killed them. My FiL was a pretty devout Catholic (though a liberal/Vatican II/Sermon on the Mount type — you know, one of the good ones) while my dad was a fallen-away Catholic (though not as fallen-away as my atheistic self).

    My dad went fairly quickly, but no hospitalization, and he died in hospice (Hospice of the Valley, wonderful group in Phoenix) after being in only briefly. He was relatively young at 72 (that’s looking a lot younger now that I’m 60) but he wanted to go and was adamantly against any extraordinary measures. That didn’t sit well with some of my siblings and other family members, but it’s what my dad wanted and my mom was ok with it too, which helped convince her to also do an AD for herself.

    My FiL was treated for his leukemia for about a year and half before he succumbed (at 83) with only a few days in the hospital during that time. He did ok till very near the end, and died in his favorite chair in his living room one afternoon. I’m glad I made one last 2000 mile trip to say goodbye to him a couple weeks before — he was the best man I’ve ever known. Like my dad, my FiL’s AD never needed to be invoked (they were both capable of giving instructions personally right to the end) but it was good to have them in case.

    My mom and mother-in-law have ADs and wills, as do my wife and myself, as well as our young-ish adult children and their spouses (there’s injury and illness, not just old age, obviously).

    None of us think about these things all the time, of course, but having “in the event” conversations and then putting the decisions made in writing is important. Families can be — no, are — messy and complicated, and decisions about medical care are at the very top of things with the potential to cause great controversy and rifts. Doing ADs won’t stop people (including medical personnel) with disagreeing about care options, but they provide the legal framework for following individual’s wishes in case they are incapacitated.

    The fascists and their “death panel” bullshit is about as fucking wrong as it gets.

  63. 63
    Wag says:

    @J R in WV:

    It sounds like an excellent hospice experieince. I’m happy that it worked so well during such a difficult time for you and your family.

  64. 64
    Richard Mayhew says:

    @Cervantes: My snark tags failed

  65. 65
    The Pale Scot says:

    But But Why would you want to avoid all that grace filled suffering?

  66. 66
    The Pale Scot says:

    I intend to make a short video of me filling an envelope with 10Gs as I explain to the camera that it’s to fund a contract on any doctor, priest or politician that interferes with my instructions.

    And a 5G bonus if the job is stretched out.

  67. 67
    Citizen Alan says:

    @WereBear:

    For all their lip service to the glories of the great Beyond, they act terrified of going there.

    The entire Rapture philosophy is based on a pervasive terror of dying along with the desperate hope that God will take the Believer bodily up into heaven without him dying first. There is a small subset of fundie Christianity that is opposed to cremation because they want to keep their physical bodies intact for the day that Jesus summons them from the grave.

  68. 68
    The Pale Scot says:

    Got enough tags there Richard?

  69. 69
    Citizen Alan says:

    @EconWatcher:

    It seems that surgeons very often lack empathy–the brain surgeon for my dad sure did–but he was also one of the best ranked in the world.

    See also “Carson, Dr. Ben”

  70. 70
    Cervantes says:

    @Richard Mayhew:

    I don’t think so — and it can be a cost-saving measure.

  71. 71
    The Pale Scot says:

    @Lurking Canadian:

    but do these numbers not strike anybody else as astonishingly low?

    Yea, that’s an odd data point. This seems a better place to start.

    Medicare spent 28 percent, or about $170 billion, on patients’ last six months of life.

    Edit: link

  72. 72
    The Pale Scot says:

    @Mnemosyne (iPhone):

    Catholic hospitals are notoriously bad about following DNR orders

    Refer to my comment at <a href="“>#64

  73. 73
    Capri says:

    Have to agree that having a person who knows your wishes may be much more helpful than an AD, because, except in the most stark cases, everything is a judgement. Most of the time, you don’t know that someone is at the end of his or her life except in retrospect.

    My father had a living will which very specifically stated that he did not want heroic measures and no ventilator – yet he was in an ICU, on a ventilator and every other thing for about a week before he passed. He was elderly with heart failure and other issues – but he had lived with them for over 5 years. He wasn’t put on a ventilator “to extend his life” he was placed on one because he had pneumonia, a condition that is often successfully treated. Ditto every other intervention, which was originally done to treat something that one might reasonably recover from.

  74. 74
    Spinoza Is My Co-pilot says:

    @WereBear:

    Ironically, the more fundamentalist Christian sects have a terrible rep among medical personnel. For all their lip service to the glories of the great Beyond, they act terrified of going there.

    It’s only anecdotal, of course (though it’s almost 40 years’ worth of such anecdotes now) but my RN wife has seen this over and over again.

    My theory on why this might be is this: the cognitive dissonance of living in a modern world while hewing to a religiously-fundamentalist worldview causes many such believers to ultimately seriously doubt their notions of the “great Beyond” when pushed hard against it at the end.

    As my fundie brother-in-law put it to me the last time we argued about evolution (we don’t do that anymore, it’s futile) — “if the science around evolution is true, then the ‘literal truth’ of the Bible comes crashing down, and I can’t go there”. I’ve known the guy for over 40 years, since well before he became a fundie and a fascist, and though I can’t get in his head any more than I can anyone else’s, I think one day when he looks into the Abyss and sees only the Abyss staring back, he’ll “go there”.

  75. 75
    Ella in New Mexico says:

    All I can say is “Thank you Medicare and about fucking time”. Seriously, anyone who does not have at least SOME form of an advanced directive today is a burden on society.

    And I say that as the ICU nurse who’s having to witness your family members brawl at the bedside over whether or not they should take 95 year-old, stage IV cancer-ridden, tube-fed Nana with end stage heart failure and on dialysis off the ventilator she’s been 100% dependent on for the past three weeks.

    Every Goddamned month.

    Look up the costs for even one day to treat the above patient in an ICU and you’ll see why I get a little angry when we DO end up pulling the plug on the tiny, fragile, pain-ridden 27 year-old with Type 1 Diabetes for which he got no primary care the last four years of his life due to lack of insurance, and who finally succumbed with renal failure, amputation, and finally sepsis.

  76. 76
    boatboy_srq says:

    @Citizen Alan: Add to that, despite the loud protestations that they are the only Blessed and Saved amongst all Humanity, the abject fear that they might possibly be wrong.

  77. 77
    opiejeanne says:

    @J R in WV: I don’t know that it was the payment on his car he was thinking about. I got the impression it was because we went against his expert advice, as well as not being allowed to “save” her. Funny coincidence, this was also at a Methodist Hospital, but the family has a long and positive history with that place. Save her for what, was the question. She was comatose with brain damage caused by the bleeding (the brain doesn’t like sitting in a pool of blood for some reason) and it was irreversible, according to the same surgeon. She wasn’t brain dead but she was pretty close at that point. She wasn’t going to wake up and be Mom again; she had been struggling with 3 different forms of dementia for a couple of years, so she already wasn’t Mom part of the time.

    The following day, when I told them to remove her respirator (that was in Mom’s AD). I wasn’t there but my sister told me the surgeon and one of the nurses said, “Oh no! She’ll die if we unhook her!” I told my sister and dad that they were wrong, that she wouldn’t die because of that, and anyway it was in Mom’s AD. The ventilator or respirator (can’t remember) was removed and she breathed on her own for another two weeks.
    Soon after, we had her moved to a nursing facility but that’s a semi-related horror story for another day, but the hospice people who were there with us most of the time were wonderful. Dad was so pleased with them, so grateful, that he made a sizable donation to their organization.

  78. 78
    opiejeanne says:

    @WereBear: Yes, we’d all like to have that miracle cure, and there have been cures or controls found for so many things that killed people just a few years earlier that it can cloud your judgment.

    When Dad was dying it was not necessary to go read his AD because we knew that it was the same as Mom’s.

  79. 79
    opiejeanne says:

    @The Pale Scot: That is monstrous, and I’ve met nuns who were dying of treatable cancer who refused the treatment because of the suffering a painful death would provide. They just said it was God’s will which it most certainly isn’t, but then I’m Protestant and therefore ill-informed about God’s will. At least one of them years earlier had counseled someone to do the exact opposite, to accept treatment as a gift from God.

  80. 80

    @opiejeanne:

    It’s one thing to decide for yourself to forego pain treatment as a spiritual exercise. It’s quite another thing to force other people to go through it involuntarily.

  81. 81
    GHayduke (formerly lojasmo) says:

    We do this with every patient on every admission. It’s required, and has been for a long time.

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