dimreepr

Cost, death, benefit analysis...

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The ethical need to sustain life, the Achilles heel of the NHS?  

Most of the cost to the NHS is in the last years of our life, and it's my intention to sign a DNR (Do Not Resuscitate) as and when my time is nigh, so as to play a small part in its continued success. 

When is it reasonable for a doctor to sign a DNR, despite the wishes of the patient, if it means a huge saving in costs and will ensure its sustainability. 

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13 minutes ago, dimreepr said:

The ethical need to sustain life, the Achilles heel of the NHS?  

Most of the cost to the NHS is in the last years of our life, and it's my intention to sign a DNR (Do Not Resuscitate) as and when my time is nigh, so as to play a small part in its continued success. 

When is it reasonable for a doctor to sign a DNR, despite the wishes of the patient, if it means a huge saving in costs and will ensure its sustainability. 

I suspect the answer is 'never'. If the cost is too great to bear by the state, then perhaps a better solution would be to sign an SSMSUC (Stop Supplying Medical Services Unless Compensated). The state should be under no obligation to spend money it doesn't have, but it should not take on the role of making the decision that a person should die at a certain time regardless of their ability to pay for services.

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Do you mean when the patient is not lucid or aware? By 'wishes' do you mean a living will where they have declared they wish for their life to be prolonged as long as possible?

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Posted (edited)
1 hour ago, zapatos said:

I suspect the answer is 'never'. If the cost is too great to bear by the state, then perhaps a better solution would be to sign an SSMSUC (Stop Supplying Medical Services Unless Compensated). The state should be under no obligation to spend money it doesn't have, but it should not take on the role of making the decision that a person should die at a certain time regardless of their ability to pay for services.

I'm not suggesting we shouldn't sustain life (pay for it if you like), I'm suggesting there's a point at which the cost outweighs the benefit. 

1 hour ago, StringJunky said:

Do you mean when the patient is not lucid or aware? By 'wishes' do you mean a living will where they have declared they wish for their life to be prolonged as long as possible?

I mean the state shouldn't have to pay for such a wish.

Edited by dimreepr

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2 minutes ago, dimreepr said:

I'm not suggesting we shouldn't sustain life, I'm suggesting there's a point at which the cost outweighs the benefit. 

I mean the state shouldn't have to pay for such a wish.

Yes, I agree.

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12 minutes ago, dimreepr said:

I'm not suggesting we shouldn't sustain life (pay for it if you like), I'm suggesting there's a point at which the cost outweighs the benefit.

And I'm suggesting it is not up to the doctor to overrule the wishes of the patient if the patient can pay his own way. It should not be up to the doctor to decide that Bob should not spend Bob's money on extending Bob's life because the doctor decided that the cost outweighs the benefit.

 

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Just now, zapatos said:

And I'm suggesting it is not up to the doctor to overrule the wishes of the patient if the patient can pay his own way. It should not be up to the doctor to decide that Bob should not spend Bob's money on extending Bob's life because the doctor decided that the cost outweighs the benefit.

 

Since the NHS is publically funded, I'm not sure where you're going with this argument?

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I think everyone is in agreement above even though it appears otherwise.

If the patient (Bob, in the example above) is willing to pay for said care privately, then he can get it and the doctor has no role in choosing for him or on his behalf.

However, if the state is paying, then at some point Bob no longer gets to decide whether or not he wants care, especially when the return is too low to justify the investment.

I believe the OP is asking: Where is that line between acceptable investment and unacceptable return? Where SHOULD it be?

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17 minutes ago, zapatos said:

And I'm suggesting it is not up to the doctor to overrule the wishes of the patient if the patient can pay his own way. It should not be up to the doctor to decide that Bob should not spend Bob's money on extending Bob's life because the doctor decided that the cost outweighs the benefit.

 

 I think he is on about a universal healthcare system. It's obvious what the outcome will be in a private system.

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It is my feeling that in a universal healthcare system, if the patient can take over payments for his care, then the doctor should not be able to sign a DNR against the patient's wishes.

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Just now, zapatos said:

It is my feeling that in a universal healthcare system, if the patient can take over payments for his care, then the doctor should not be able to sign a DNR against the patient's wishes.

I believe nobody here is suggesting otherwise

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Posted (edited)
45 minutes ago, dimreepr said:

I'm not suggesting we shouldn't sustain life (pay for it if you like), I'm suggesting there's a point at which the cost outweighs the benefit

The cost is not only financial but also personal/spiritual (whatever you want to call it). Depending on what you are dying of, it is likely to be quite a slow, uncomfortable and completely undignified process - especially if you are in a hospital bed.

DNR doesn't mean much: literally do not attempt resuscitation. It is not the withdrawal of treatment as people sometimes think. Sign DNR and you should still be treated in the exact same way as some who is for resuscitation. Most resuscitation attempts end in death anyway (approx 4/5 in-hospital attempts iirc). Withdrawal of treatment is another thing, with another layer of ethical consideration. 

 

2 hours ago, dimreepr said:

Then is it reasonable for a doctor to sign a DNR, despite the wishes of the patient, if it means a huge saving in costs and will ensure its sustainability.

Many patients are incapacitated and do not have an advanced will and so the decision goes to next of kin. They are generally not in an ideal emotional state to literally be making life and death decisions and nor are they provided much support (very much depends on the ward and hospital). It is quite common to see families start resolutely with 'my pa would want to fight til the end', but after watching their father shit themselves constantly for two weeks begin to realise the undignified realities of dying.

Doctors make the decision based on whether it makes medical sense (i.e. likelihood of success and quality of life thereafter). Good doctors (palliative care docs, which you'll generally only get if you are dying of cancer, which most palliative cases are not) might actually take into account the dignity of the patient, but i've rarely seen it. Nurses are generally crap at advocating for their patients for various reasons requiring its own thread (again unless you get some palliative care nurses, again generally only for cancer patients).

If we want a good death to be a viable option (and i think we absolutely should), then we require more training for doctors and nurses, and just more nurses so they can actually dedicate some real time to emotional/spiritual support of the patient and family. This is a lot of investment, i'm not sure it would save money - it might actually cost a bit.

The infamous Liverpool care pathway was an attempt at this, but as all things in nursing, it became an exercise in paperwork and bureaucracy and soon hit the tabloids as the death pathway. In my opinion its not the pathway that was the problem but the set-up of the entire nursing profession - but that's another discussion. Having something of that kind is a good idea.

By the way, this is where a learnt to respect a lot of priests and imams. They would do a much better job of providing support to patients and families than nurses would.

 

Edited by Prometheus

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2 minutes ago, iNow said:

I believe nobody here is suggesting otherwise

StringJunky agreed my statement applied in a private system, but did not concede it applied in a universal healthcare system.

dimreepr similarly has not conceded that my statement applied in a universal healthcare system.

I don't know if that is because they disagree with me, or if it is because they are not seeing the distinction I am making.

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1 minute ago, zapatos said:

StringJunky agreed my statement applied in a private system, but did not concede it applied in a universal healthcare system.

dimreepr similarly has not conceded that my statement applied in a universal healthcare system.

I don't know if that is because they disagree with me, or if it is because they are not seeing the distinction I am making.

I thought that you were thinking in terms of the US system only, quite naturally.

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Just now, StringJunky said:

I thought that you were thinking in terms of the US system only, quite naturally.

Understood. I was discussing the NHS proposal that dimreepr suggested.

In the case of NHS, do you think a patient should always be able to take over payment for his own care, even if NHS refuses to pay any longer due to a determination that the cost is no longer acceptable?

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8 minutes ago, Prometheus said:

The cost is not only financial but also personal/spiritual (whatever you want to call it).

Indeed, but the point still exists.

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Posted (edited)
12 minutes ago, zapatos said:

Understood. I was discussing the NHS proposal that dimreepr suggested.

In the case of NHS, do you think a patient should always be able to take over payment for his own care, even if NHS refuses to pay any longer due to a determination that the cost is no longer acceptable?

Prometheus is probably better informed, but I don't think the care team would go along with it because, in their assessment, any further effort is actually futile. There are precedents of this where parents have taken the NHS to court to get their unresponsive/terminally-ill children treated elsewhere... and usually lost. If it's that difficult for children, it's highly unlikely it is permitted for an end-of-life patient. From their position, it's unethical to keep going on with it.

Edited by StringJunky

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1 minute ago, StringJunky said:

Prometheus is probably better informed, but I don't think the care team would go along with it because, in their assessment, any further effort is actually futile. There are precedents of this where parents have taken the NHS to court to get their children treated elsewhere... and usually lost. If it's that difficult for children, it's highly unlikely it is permitted for an end-of-life patient. From their position, it's unethical to keep going on with it.

So the state is essentially deciding that a patient should be allowed to die rather than live (or at least try to live)? Even if all the state has to do is say "I am releasing you from my care into the hands of other care givers"?

Sorry, but having a hard time registering this. Your system allows the government to decide to allow someone to die under certain circumstances, even if it can simply remove itself from the equation and let individuals decide for themselves what to do? (now I'm repeating myself)

If so, I find that to have similarities with the US stance on the death penalty. We can allow inmates to live but instead take actions that result in someone's death. Seems eerily similar to me.

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11 minutes ago, zapatos said:

Your system allows the government to decide to allow someone to die under certain circumstances

More specifically, their system allows the government to decide they'll no longer pickup the check. The death and alternative treatment decisions still stick with the patient.

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Posted (edited)
19 minutes ago, zapatos said:

So the state is essentially deciding that a patient should be allowed to die rather than live (or at least try to live)? Even if all the state has to do is say "I am releasing you from my care into the hands of other care givers"?

Sorry, but having a hard time registering this. Your system allows the government to decide to allow someone to die under certain circumstances, even if it can simply remove itself from the equation and let individuals decide for themselves what to do? (now I'm repeating myself)

If so, I find that to have similarities with the US stance on the death penalty. We can allow inmates to live but instead take actions that result in someone's death. Seems eerily similar to me.

It has even gone all the way to the highest European Court and they've agreed. What you''ve got to realise is that there is no practical limit to the care given and the case is actually medically futile, after consultations with independent authorities. Dimreepr is saying there needs to bean earlier cutoff point and not just automatically throw limited  resources on hopeless cases, as we are doing currently.

Edited by StringJunky

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12 minutes ago, iNow said:

More specifically, their system allows the government to decide they'll no longer pickup the check. The death and alternative treatment decisions still stick with the patient.

I don't think that is what StringJunky is saying.

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3 minutes ago, zapatos said:

Your system allows the government to decide to allow someone to die under certain circumstances, even if it can simply remove itself from the equation and let individuals decide for themselves what to do? (now I'm repeating myself)

If a patient can decide for themselves then it is usually not disputed, although it may be discouraged if it really will lead to some bad times for the patient (and the bad times can be really bad). Technically a doctor can enforce DNR on a patient, but i think that's extremely rare (and could go to court). Usually, however, the patient is unable to give input so the family (if any) decide. Doctors may again disagree if they believe it is not in the patient's interest. The doctors cannot be forced into a medical treatment (in this case CPR) if they believe it will result in suffering for the patient. 

If you go private, those doctors will be making exactly the same decisions - they won't just give you want you want because you want it (although maybe the money does play on their minds).

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5 minutes ago, StringJunky said:

It has even gone all the way to the highest European Court and they've agreed. What you''ve got to realise is that there is no practical limit to the care given and the case is actually medically futile, after consultations with independent authorities. Dimreepr is saying there needs to bean earlier cutoff point and not just automatically throw limited  resources on hopeless cases, as we are doing currently.

Yes, I got distracted from demreepr's point when I started thinking about what you said. I need to ruminate on it a bit as I didn't quite realize how things worked there.

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4 hours ago, dimreepr said:

The ethical need to sustain life, the Achilles heel of the NHS?  

Most of the cost to the NHS is in the last years of our life, and it's my intention to sign a DNR (Do Not Resuscitate) as and when my time is nigh, so as to play a small part in its continued success. 

When is it reasonable for a doctor to sign a DNR, despite the wishes of the patient, if it means a huge saving in costs and will ensure its sustainability. 

All health systems, including the NHS have a limit to what is being approved to sustain or improve life. This includes procedures a relatively hard upper limit. In the end-of-context, often the costs are calculated as added quality-adjusted life years (a measure of quantity and quality of life). In the US, often something like $40-60k per added year. If a procedure exceeds that it may be denied. Resuscitation is probably not a good example, as it usually at the less expensive end, and often have low success rates. It is more relevant in the context of continuous life-extending procedures. 

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It should be noted that even in context of private healthcare limits apply. I know this all to well having a preexisting condition. I can sometimes barely even get my approval for my preferred daily needs despite paying for the coverage out of my own pocket. No system is unlimited. In some systems, the government imposes those limits while in others the private insurer imposes those limits. It's only "free" in the way many of us seem to prefer when we can afford to pay the total cost completely out of pocket and absent any help from others.

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