dimreepr

Cost, death, benefit analysis...

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12 minutes ago, jajrussel said:

If it becomes apparent that I'm not going to heal, or I'm simply dying of old age

It’s this specifically which folks are discussing

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5 hours ago, iNow said:

It’s this specifically which folks are discussing

I see you, are right, I did wax philosophical, about an ethics question. I'm sorry. I did drift.

The need to substation life becomes an ethics question the moment the state assumes the responsibility to end life against the wishes of a patient. In the original post position the doctor acts an an agent of the state assuming the responsibility of life and death. If the cost to sustain life is considered to high by the state, then it is the state that is the Achilles heel.

The original post ties the doctors decision to cost. It is unethical for the doctor to refuse treatment based on cost as an agent of the state. Therefore, it is never reasonable for a doctor to sign a DNR based on the cost to the state.

The conversation did drift toward a private system.

The same could be applied to a private insurance system it is generally the private insurer assuming the responsibility given to the doctor in the original post, and is still unethical.

Edited by jajrussel
Spelling correction. And further thought.

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22 minutes ago, jajrussel said:

The original post ties the doctors decision to cost. It is unethical for the doctor to refuse treatment based on cost as an agent of the state. Therefore, it is never reasonable for a doctor to sign a DNR based on the cost to the state.

The counter argument is that sustaining a life will cost the healthcare provider money. This money is not an infinite resource; by spending money on keeping one person alive necessarily impacts upon the care, and even the life or death, of another person. At some point it will become unreasonable to sustain one life at considerable cost: the money would do more good and save more lives spent elsewhere. These things are already considered in the UK when deciding whether to licence the use of certain drugs. The question is whether to extend it to DNR decisions.

There is always a case that resources can be diverted away from, say, military spending (a common argument in the UK) to avoid such problems but i think that's just kicking the can down the road. 

I'm not sure it would save much money. Many signing DNR go on to die relatively soon anyway (can't remember the figures right now) and i would hope we divert resources into good end of life care (currently lacking in the UK) which might up eating up any financial savings. However, if it improves end of life care i think this would be preferential.

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1 hour ago, Prometheus said:

The counter argument is that sustaining a life will cost the healthcare provider money. This money is not an infinite resource; by spending money on keeping one person alive necessarily impacts upon the care, and even the life or death, of another person. At some point it will become unreasonable to sustain one life at considerable cost: the money would do more good and save more lives spent elsewhere. These things are already considered in the UK when deciding whether to licence the use of certain drugs. The question is whether to extend it to DNR decisions.

There is always a case that resources can be diverted away from, say, military spending (a common argument in the UK) to avoid such problems but i think that's just kicking the can down the road. 

I'm not sure it would save much money. Many signing DNR go on to die relatively soon anyway (can't remember the figures right now) and i would hope we divert resources into good end of life care (currently lacking in the UK) which might up eating up any financial savings. However, if it improves end of life care i think this would be preferential.

It could also be argued that the patient paid into the system as designed by the system and is intituled to due consideration much more so than the decision to withhold treatment based on cost. The cost has already been considered, and the patient duely charged. The doctors responsibility is to the patient, and the Hippocratic Oath. Not, to the financers.

The actual Healthcare  providers lose money because the financers don't want to hold up their end, and note it is not the financers money. That money is placed in trust, and in truth they defy the responsibilities of that trust by refusing to make that money available to the provider.

A doctor refusing treatment based on financial cost is acting unethically. The doctor should change jobs if his or her first concern isn't for the patient. If the patient wants to sign A DNR it's no longer a question of ethics, and the doctors can do what they do best without the fear of being second guessed by the state or the insurers.

Edited by jajrussel
As always, spelling.

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2 minutes ago, jajrussel said:

A doctor refusing treatment based on financial cost is acting unethically. The doctor should change jobs if his or her first concern isn't for the patient. If the patient wants to sign A DNR it's no longer a question of ethics, and the doctors can do what they do best without the fear of being second guessed by the state or the insurers.

But the doctor isn't just concerned with THE patient: they will have many patients. Any decision regarding one patient will likely have an impact on another patient, including financial decisions. Doctors will already sometimes triage patients in extreme situations, choosing not to save one person in order to focus on someone else more likely to survive. Financial limits exist and they force these life and death decisions.

Yes each person has paid into the pot, but it's not an infinite pot and paying in shouldn't mean you can take out so much it's to the detriment of others. If you want to pay into your own pot we have private healthcare insurance too.

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6 minutes ago, Prometheus said:

But the doctor isn't just concerned with THE patient: they will have many patients. Any decision regarding one patient will likely have an impact on another patient, including financial decisions. Doctors will already sometimes triage patients in extreme situations, choosing not to save one person in order to focus on someone else more likely to survive. Financial limits exist and they force these life and death decisions.

Yes each person has paid into the pot, but it's not an infinite pot and paying in shouldn't mean you can take out so much it's to the detriment of others. If you want to pay into your own pot we have private healthcare insurance too.

The existence of the QALY system is testament to those constraints, isn't it?

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3 minutes ago, StringJunky said:

The existence of the QALY system is testament to those constraints, isn't it?

Yep. CPR isn't assessed by NICE though. If they did that US study i linked to earlier suggests they wouldn't offer it to octogenarians at current thresholds.

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19 minutes ago, Prometheus said:

Yep. CPR isn't assessed by NICE though. If they did that US study i linked to earlier suggests they wouldn't offer it to octogenarians at current thresholds.

Yes, I just meant it as indicative that such thinking exists within the health system. National ones anyway.

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14 minutes ago, StringJunky said:

The existence of the QALY system is testament to those constraints, isn't it?

Being American this is the first I've heard of it. After a quick read it seems a reasonable attempt to be reasonable. However, a doctor refusing treatment based simply on cost seems like an attempt to end around the QALY system.

There comes a point where repeated CPR to an octogenarian becomes pointless and possibly cruel, but I would hope that without a DNR at least one or two tries would be allowed. I'll have to follow the link. I find it hard to believe that an octogenarian who was reasonably active before an event would be denied CPR based on their age.

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5 minutes ago, jajrussel said:

Being American this is the first I've heard of it. After a quick read it seems a reasonable attempt to be reasonable. However, a doctor refusing treatment based simply on cost seems like an attempt to end around the QALY system.

There comes a point where repeated CPR to an octogenarian becomes pointless and possibly cruel, but I would hope that without a DNR at least one or two tries would be allowed. I'll have to follow the link. I find it hard to believe that an octogenarian who was reasonably active before an event would be denied CPR based on their age.

I think we've been down this road before, where Prometheus explained the generally poor outcome of CPR.

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On 4/11/2018 at 6:41 AM, Prometheus said:

I don't think the OP has been answered. Currently any decision regarding CPR by NHS staff involves only the probability of success and projected quality of life thereafter - it never involves financial considerations. The question is whether it should: it's not really the kind of question that can be definitively answered.

QALY is not used in the day-to-day assessment of patients (at least in the NHS). It is used by NICE to rationalise the price of treatments, but i do not think they have ever assessed CPR . I did come across this US study though which estimated the price of one QALY for octogenarians at ~£44,000, which is above NICE's threshold for cost-effective treatment, which has an upper limit of ~£30,000. By these numbers there could be a case for not offering CPR to people over 80 on the NHS but that kind of 'one size fits all' approach might mean some 80 year olds who would potentially do well post-CPR are essentially being discriminated against based on age.

After reading this post I would I would assume that if CPR was not accessed by NICE then they are assuming that CPR is not in need of assessment because in general it will likely be tried until it becomes evident it isn't working then the patient moves into a classification where it should be denied according to guide lines.

3 minutes ago, StringJunky said:

I think we've been down this road before, where Prometheus explained the generally poor outcome of CPR.

You are right.

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An interesting related article.

Quote

The parents of Isaiah Haastrup, a 12-month-old with profound brain damage, have lost their legal battle to appeal against a decision allowing doctors to withdraw his life support.

 

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9 hours ago, iNow said:

It’s this specifically which folks are discussing

I misread this, I thought you had indicated I had gotten off point, so I got on point a little more than I should have. My eyes saw, is this, rather than, it's this. You were making a statement. I thought you were asking a question. :mellow:...

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The desire was to clarify not to cloud. Alas, we can’t always get what we want. No worries 

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