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.

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.

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.

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.

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.