A 90-year old man with a pancreatic mass, almost definitely pancreatic cancer, was admitted to a hospital.
Surgeon Jeffrey Parks does the initial surgery consult on this terminal case, and recommends hospice care.
The next evening, he’s shocked by the “astounding amount of medicine [that] had been practiced” during the day:
Consults had gone out to GI, oncology, and nephrology. The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.
It’s often said that we spend the most money in the world on futile care, often with little benefit to the patient. The preceding account was that phenomenon in action, replicated thousands of times on a daily basis.
A microcosm of what’s wrong with American medicine indeed.
Related posts:
- Futile care
- Futile care
- Futile care
- Discussing end-of-life care in the ICU and saving Medicare money
- Passing the futile care buck
- Taking a stand against futile care
- Futile care, again
{ 31 comments }
What can one do when the patient or the family refuses hospice/ comfort cares and wants the patient full code with all the medical therapies active.
Even though it is futile care, to not treat or at least not evaluate can lead to a futile defense in a medmal trial. One would hope people would say enough is enough but unfortunately it is not the case. The economics are huge and so are the legal ramifications.
I woulnt mind it if he or his family was paying. Patients need to have a greater financial stake. Not cheap care for all.
In the case above, I wonder if more “medical homes” would not help, where a medical team plans a course of action for a patient with cancer rather than all the doctors making decisions independently. In his short-lived confirmation hearings, Daschle had listed medical homes as a priority for HHS.
I think part of the problem for patients/families is that terms like “end-of-life” care need to be defined. I had a discussion with someone last night who assumed end-of-life care meant any care for a terminal patient. They thought Obama yesterday called for a plan that would cut off treatment for terminal patients. I explained that, at least in oncology sessions I have attended and studies I’ve reviewed, end-of-life care is typically described as care for those patients for whom the care will have no benefit. Nobody is suggesting eliminating palliative care for terminal patients, which is care that improves their quality of life.
We have written about studies on this in OBTN and it was addressed at ASCO this year extensively: Oncologists need to have end-of-life discussions with patients where applicable. Patients may not even realize they only have a few more weeks left and that the treatments are hurting their quality of life more than any benefit they are likely to impart.
Exactly Anon 9:18. If he’s paying who cares? If he wants that care and can afford it, good for him. Nothing at all wrong with that.
“One would hope people would say enough is enough but unfortunately it is not the case. ”
One also wonders if the physicians performing all that care ever explained to the patient or the family the pointlessness of it all, or simply saw an opportunity to do some billing.
Why are you blaming the patient?
It’s clear from Dr. Parks’s post that after some discussion, the patient and his family agreed to focus on comfort measures rather than aggressive care.
Reading the original post, it sounds to me like this was a case of the specialists plowing full speed ahead without taking the time to communicate.
I think I just solved a large part of the health care crisis in the US.
All malpractice attorneys and members of congress should be forced to VOLUNTEER time on “life or death” councils – the kind they had for dialysis patients before 1973, where an anonymous group has to decide who does and doesn’t get “every last medical benefit” available and their decisions are binding and final unless a family wants to pay out of pocket for said “futile care.”
Anonymous 10:57 – my apologies, but you missed the point completely. The stat MRCP, CT and renal tests were all done BEFORE anyone could “get it together and decide with the family” … and they were done EXACTLY because doctors get sued every day for not “doing everything they possibly could for my grandpa!!!” … hence my suggestion.
There seems to be very little reason for all these specialist to get involved. The internist should have sat down and talked to the patient (there was no mention of mental status changes that would preclude it), or discussed it with the son. Even if there was concern about a medmal trial, I would have only gotten the oncologist involved after discussion with the son/family about the poor prognosis if they were not understanding the situation. This would be with with the idea that the options for treatment would be laid out as mostly futile, or if even considered then likely to make his last days painful.
I don’t think you can disregard the wishes of the patient or his/her family members. If any of them requests further workup you better follow their wishes or risk not only a lawsuit for medical malpractice but also for elder or dependent care abuse which carries enhanced remedies not subject to State limitations (in California). It is a tough position to be in.
Dr_Mnenomic: I would volunteer on such a “council”. By the way, I represent health care providers so I’m not sure if you were aiming at the Plaintiff or Defense bar in your comment.
” and they were done EXACTLY because doctors get sued every day for not “doing everything they possibly could for my grandpa!!!”
What evidence is there for this claim? Who is out there reading case results and determining this is what you MUST DO in order to avoid being sued? Can anyone point to a single case similar to this guys where someone paid on a malpractice claim? You can’t simply blame everything you do on others because of a few stories you heard.
And does no one really believe that there wasn’t a profit motive among all these physicians doing this work? None at all?
FREE=MORE
Oh yeah. That patient could have been mine, 5 times last week.
Well, excuse me, Dr. Mnemonic, but what information in the original post suggests that the only reason this poor patient received the full monty was because the docs were afraid of being sued? You’re jumping to conclusions here.
Based on the original post, it doesn’t appear that the patient and family took a great deal of convincing to opt for comfort measures. Maybe most of the aggressive, expensive measures that posters here are complaining about could have been minimized or avoided with better communication up front.
Based on the fact that Dr. Parks seemed surprised and dismayed at all the intervention ordered by the specialists, it sounds as if communication wasn’t really happening among the medical team either.
If you want to know who isn’t getting the point, I suggest you take a look in the mirror.
An economic fundamental has been ignored, certainly in South Africa – where margins are forced to be low, volumes have to be high to survive. Ergo overservicing!!
I agree, this situation is ridiculous, but happens thousands of times over every day in every country.
We see these cases every day. The medical industrial complex has a huge appetite that must be fed to survive. Most excessive medical care in this country is not futile,but is simply unnecessary. One way to drastically reduce it would be if patients and their families bore some financial responsibility for their medical treatments and tests. Similarly, when you’re at an expensive restaurant, and someone else is paying the check, you order surf & turf instead of fish & chips http://www.MDWhistleblower.blogspot.com
Let’s stop pointing fingers.
We all need to change.
Doctors need to stop ordering so many tests, a patients/families have to be more reasonable with their expectations.
I have no doubt that many of these procedures (e.g. ERCP???) were done 99% for profit/billing and 1% to avoid a medmal suit.
Really, can any experienced gastroenterologist really think they can’t defent NOT doing an ERCP on a 90yo terminal pancreatic cancer patient?
I think it’d be much harder to defend DOING the procedure, especially when the patient dies on the table, a month before he would’ve died anyway from his cancer.
While I do agree that medmal lawyers are really leeches who contribute absolutely nothing to society, in this case Matt is correct.
And is “palliative chemotherapy” really for anything but billing (besides of course making people suffer at the end of life)?
Even attending oncologists admitted this to me during a brief stint as an oncology fellow.
Dr Parks’ post seems to indicate the pt’s son was contacted when his father was admitted, and that the pt’s condition was stable.
As others have pointed out, there was no urgent need for the consults and testing performed prior to the son’s arrival. What we had here was a failure to communicate, unless there was another driving force, such as quotas or revenue (i.e., if your group doesn’t provide sufficient pt volume (#s of procedures, $ amount, whatever), your group gets replaced by some other practice that says they can generate the necessary numbers.) This case reminds me of our fine local police department’s practice of “revenue enhancement” through speed traps, red light/speed cameras, and overly zealous parking violation enforcement.
@Dr_Mnemonic, KW Esq, Happy Hospitalist – “Life and death councils” should be resurrected. Persons wanting futile care for themselves or family members should have to pay in full. As Happy says, “free=more”. I suspect one of two things would happen if futile care weren’t “free”: either people might change their minds about receiving it, or they’d try to game the system to get as much “free care” as possible done in the ED.
The problem I have with the Happy quote, and I may be totally misinterpreting it, is that the “free= more”, puts all the onus on the patient. Patients may be demanding more futile services because they are free (anyone have any proof of this?), but someone, somewhere is profiting from these services. Maybe if doctors were not getting reimbursed for futile care, they would stop ordering futile interventions.
In response to Reality Rounds and everyone else invoking a financial motive for the doctors actions, most of the procedures mentioned above would not directly benefit the physicians ordering them; i.e. the MRCP and CT-guided biopsy which are performed by the radiologist, and the battery of lab and urine tests ordered by the nephrologist (which I’m sure included a renal ultrasound, also benefiting the radiologist). If the GI doc was purely profit driven he would have skipped the MRCP and went straight to ERCP. There’s obviously something more going on here than merely fear of lawsuits and profit motive. Testing and intervention is the culture of medicine. That is what we’re trained to do. As a frustrated intern I once asked a nephrology fellow why he had written a three page consult note with two pages of recommended testing on a fairly straightforward case (which probably didn’t need a renal consult to begin with). His response: “What did you expect? You called a renal consult. That’s what we do.”
The last anonymous comment is correct. Financial incentive is hardly the overriding issue. Let’s face it, in the hospital, speed matters (reduced length of stay is strongly promulgated by the hospital). Also, communication is often done via the chart – which means only the next day do physicians read what other physicians are thinking is the ‘right’ answer. Lawsuits are certainly a concern – making sure the diagnosis is correct is part of the reason for the work up that ensued in this case. There are also differing degrees of comfort among physicians regarding how far to go. There is almost never a backlash for going ‘too far’, until the patient or family says so we are going too far – at that point the physicians will finally relax and back off of their testing. The ‘machine’ of the hospital works for the majority of people who CAN be saved – its just that putting on the brakes of that machine can take a few days.
BTW, one of our physicians was sued BY A PATIENT’S FAMILY for ALLOWING their family member to die when the patient coded and had a valid DNR order on the chart! The patient had terminal pulmonary fibrosis and was very clearly mentally able to make this decision. The family was angry that THEY were not consulted regarding the DNR order. The physician won the case, but not without a lot of pain to him personally. Lawsuits are an ever present threat in the medical world and those who don’t know this aren’t practicing medicine.
Let me make it clear to Matt and others.
Physicians don’t want to do this. This kind of futile care is disgusting and the most disatisfying part of my job. I don’t need any more work to do. There is no incentive to do this for “extra billing”.
More than not when I talk to families about providing compassionate supportive comfort care they look at me like there are horns on my head. They say, “do everything to save him/her”. I say I can’t save her but I can only prolong her torture……..The family still wants to flog and torture……….even though they would not want the same for themselves. There is some kind of sick psychology out there that needs to be addressed in the health care debate.
LEGAL CONCERNS David’s comment #24 illustrates the primary relevance of legal concerns here. The risk of liability is exceedingly low in most cases. I examined every litigated case where physicians stopped life-sustaining treatment contrary to surrogate wishes. Providers were successful in the overwhelming majority of these cases. But they still had the stress of the litigation itself (depositions, interrogatories…).
http://works.bepress.com/thaddeus_pope/3/
http://www.medicalfutility.blogspot.com
Matt and anonymous (pick a name and put in a fake email so we can address you unambiguously, please)
You need only go to any ICU in any big hospital and spend a week there and you will see the “evidence” you seek, or review the cases that are WON by doctors to see what they had to endure for “doing nothing wrong.” Look at post #24.
Even when the family member of the dying patient is a doctor or nurse (it happens a lot) there are still pleas of, “Do everything you can…” when the odds are so overwhelming against a favorable outcome that everyone but that one person in the room begging for a little more life for grandma knows the inevitable. Do miracles happen? Yes they do, but at what cost? .. and soon, at what cost to taxpayers both to grant them and to explain to juries why they were extremely unlikely.
With 32 years of experience as an Internest let me say it is primarily all about the money. The admitting doc was probably a PCP who is not going to get paid for the time it would take him to educate the patient and family about the futility of agressive care in this case. So he orders a couple of consults. The consultants order more tests and more consults . The snowball has started down the hill. The way to stop this would have been for the patients PCP to have had a end of life discussion with the patient and family 6 months ago before he got sick so there is not the pressure to “do something”.
I agree with you TrenchDoc, and though I am just starting as an intern, my last two rotations were family medicine and every new adult patient was asked, “Do you have a living will?”
But as was mentioned in post 24, even with DNR’s in place, doctors still get sued. It’s crazy. I was arguing with a friend of mine who is a teacher and said, “What if you could get pay docked or fired every time a student got a grade that his parents were unhappy with?”
You know as well as I do that this is what we are talking about: doctors taking extreme measures to avoid losing or even settling lawsuits in which they did NOTHING wrong.
I am a surgeon. I read the case vignette, and here are my comments.
Certainly the consults to the surgeon and the various specialists by the PCP could have been avoided with good management of expectations. TrenchDoc is right when he says that this lack of communication can arise from a financial disincentive. If a family wants an extensive discussion (as families are wont to), time is a commodity that has to be funded. Aggressive and futile care in the elderly is found primarily in private healthcare systems both in America and internationally.
Nonetheless, it is true that America has a far higher proportion of individuals who would resort to legal action than the rest of the world, and that there is a strong sense of entitlement and a lack of acceptance of rationing. That the healthcare system evolves along a similar direction guided both by the practitioners and those practised upon is not surprising.
With regards to BuckEye Surgeon’s comments :
(a) I agree that the benefit / risks of the various procedures have to be considered in terms of discomfort / time. I cannot see the value of an MRCP / ERCP here since the projected survival is probably less than 3 months, and he was not overtly septic. There is probably no benefit in alleviating asymptomatic jaundice. If it was done for the possibility of chemotherapy, this procedure should be best recommended following discussion with the oncologist (BTW, not the surgeon, please feel free to leave me out).
(b) The CT guided biopsy may have been requested by the patient, and is often important for the patient/ family to come to terms with a definitive diagnosis. Perhaps the gastroenterologist or oncologist sat down with the patient (instead of writing up a note for hospice referral stat), and explained that this is 99% cancer, and a bad one too, and we would really accept it as such, but it’s your call. There are some patients that need that certainty. In any case, presumably *informed* consent was taken from the patient.
(c) Palliative chemotherapy. I would certainly take my oncology colleagues’ opinions about chemotherapy into account and discuss patients with them before writing unpleasant notes that “their chemotherapy is ill-advised”. Perhaps the oncologists are thinking of a gentle regimen, after balancing possible benefit and risk. In fact, in my experience, surgeons are usually more guilty of excessively heroic ‘ill-advised’ actions, particularly in cancer surgery, with much greater fall-out.
(d) As for the nephrology consult (presumably arising from raised creatinine due to dehydration and hepatorenal syndrome) with a resulting barrage of blood and urinary tests, generally, I would agree most tests are unnecessary beyond simple initial hydration and a review of the patient’s drugs.
was the conclusive diagnosis of terminal pancreatic carcinoma was arrived after the exams and diagnostic procedure such as ERCP with a positive tissue biopsy and ct with undeniable metastatic spread? Conclusive diagnosis decision/plan arrived at after the facts are obtained.
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