Chris Rangel wonders why he’s ordering a CT scan on this 95-year old:
Physicians are trained to do react to symptoms with tests and treatments and to proceed in this direction until a cure is achieved, the problem resolves, comfort is attained, or a terminal/incurable condition is found. But this 95 year old had dementia, diabetes, hypertension, and unexplained anemia. I was in a gray zone here. Was being 95 and in poor health enough to consider this a ““terminal condition”?The other parts of this problem of “do everything” medical care is the lack of restrictions on test ordering (the lack of a “stick”) and the presence of motivational factors like patient/family expectations and so-called defensive medicine (the plethora of “carrots”). For the physician, patient, and family there are few downsides to ordering tests that are noninvasive and relatively harmless. But we don’t practice in a vacuum. The real harm is to the system that must sustain an enormous amount of unrealistic and often unnecessary and pointless spending.
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And if you had “missed” a head bleed on a 95 year old what “family” would come out of the woodwork accusing you of malpractice. Add onto that a scum sucking attorney ready to make a quick buck. Hence everyone gets a head CT. No matter how stupid.
The fact is we all die and the vast majority of times it has nothing to do with malpractice (except in the legal world).
I agree, and yet I order them, too. Into the office comes the very old patient, in their tenth decade sometimes, but with the concerned middle-aged grandson or daughter (or in some cases great-grandson/granddaughter) wanting to know exactly what is wrong with granny. Often the complaints are nebulous and the patient unable to cooperate, if good-naturedly. Old stroke or new stroke or no stroke? Ischemia or no ischemia; vasculitis or no vasculitis, it is sometimes hard to tell. But they came with questions, looking for answers and presumably at least an offer of treatment, even if only to be politely declined. Am I to be the one to say this old person should not be treated since their life expectancy, while not exactly knowable can’t be very long, and that a reasonable cost-benefits analysis would suggest stopping right there? Not in this country. So I investigate as I would with anyone else, looking for explanations leading to recommendations that probably will be refused anyway.
This isn’t really a moral conundrum. It is all about resources, and those who consume them feeling responsible for their stewardship and conservation, or not. The UK, which is no more a moral wasteland than the USA has a simple way of dealing with this. The government there just says no, and that doesn’t seem to be such a problem. Maybe there people don’t expect to live forever, or expect that natural death isn’t preceded by some decline.
Where does the Govt. in the UK just say NO to treating old folks? Dr. Crippen talks quite a bit about the old folks he treats.
The entry hallway into a hospital should be a conveyer belt through x-rays, CT scans, MRI’s, and yes, Colonoscopies.
Only after all that may you see the doctor.
The entity that needs to “just say no” is the entity paying the bill. Until taxpayers vote to just say no, the pot will be steadily depleted. Doctors and hospitals have every disincentive to just say no. The fact is that unless a patient has their own personal or family resources they want to voluntarily spend to rule out that 1% chance of the incurable or vegetative-state prolonging condition that would otherwise be missed and expose providers to potential liability, somebody needs to say no. Hospice, rational relatives, and living wills help in the meantime.
Beajerry: In view of another current and ridiculous situation, I offer this modification of your statement:
The entry hallway into an airport should be a conveyer belt through x-rays, CT scans, MRI’s, endoscopy and yes, Colonoscopies.
Only after all that may you board the airplane.
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