The fraud reported in the 60 minutes segment I was referring to was about bogus companies that set up closed door shops in minimalls and sold non-existant medical equipment to phantom people, then billed the government. Not what you stated in your post.

I will make the assumption that the author simply desires to make a point that we as a health care community can do better for our patients and that discussing end-of-life issues is an important part of good medical care. However, past this ideal, little of her argument helps the reader understand the truths about ICU patients because she mixes fact with partial fact.

The author begins with the enormous cost of ICU care. This very general broad stroke is painted and creates the initial problem. There are many differences between “ICUs” (Surgical, Medical, Cardiac, Cardiovascular, Neurosurgical, Transplant), and their respective patient populations. This should have been more focused because the author then grabs statistics (below) from a study that describes nursing home residents (a narrow population). The author’s argument is now poorly framed and setup for controversy (mixing broad fact with narrow factoid).

“More than half of those patients who survive a prolonged critical illness die within the subsequent year.” and “Even more discouraging is that fewer than 10% are actually at home living independently.”

The reader is left to believe that somehow, ALL ICU patients have a 10% chance of living independently and have less than a 50% 1 year survival. Then the author delves into the end-of-life debate with this money argument. That is a mix that only serves to stir up the pot. I would argue that you can sell the end-of-life discussion very well if you leave money out of the picture. People understand good-intentions and caring doctors. But throw money into it and you have completely given up those ideals. What ensues next is the mudslinging and misdirection from the readership.

For example – Diane J Staniford: “Be a doctor. If you are not a doctor to heal the sick, please find another job. Try Wall Street if you are into stats and dollar costs.” and Finn “What is “Other Spending”?”.

These statements from the readers really mean the topic of end-of-life discussion is completely lost. The fact is, this is a really important topic. End-of-life discussions are meant to be inclusive of the patient and family belief systems with the physician playing a role of information expert, thus delivering and explaining information in such a way as to help that patient or family make the best decision(s) possible. Despite what the author says, long-term outcomes of ICU patients are, in general, very encouraging in a broad sense. However, there are indeed many patients with truly critical illness that we cannot predict with certainty what their individual chance of survival will be acutely, not to mention long-term. We can only utilize our understanding of statistical probabilities to help best inform and serve our patients and their families.

So, my take. End-of-life discussions are important. Statistics, when used intelligently and honestly are important. Put the two together to best help your patients, with everyone understanding that there are limitations to what we know and what we can do.

note to Diane J Staniford: Medicine is a profession that must rely heavily on statistical probabilities to make the most informed decisions possible. This fact does not impair personalized medicine, but is in fact is the best tool we have available in a world of made up of probabilities and a future that nobody can predict. Therefore, your inflammatory comment about leaving medicine and going to Wall Street is not valid and deserves retraction.

JFS

But if you believe that story and the rooney segment that aires along with it, then you are likely not in medicine. the fact is a lot of what is considered ‘fraud’ is only so because of paperwork which is not filled out to the medicare specifications. it does not reflect work that was not done. if you took a look at tis from the opposite side, which I never see done, you would be astounded at the amount of things which get done by clinical people which never get reimbursed by medicare because a T was not crossed, or an I not dotted.

Furthermore, you are “shocked” that 40% of nursing home residents with advanced dementia In cited prospective study undergo at least one “burdensome” intervention, including a hospitalization or an ED visit, in the last 3 months of life. I am sure that my caring colleagues in the ED and hospital don’t see their interventions as “burdensome”. Why do you?

Finally, paternalistic medicine is dead, patients are free, free to fight for life despite the prognosis and cost. Would you have it any other way?