Palliative Care vs Just Busine$$
Here is a true story of a decision made by the patient and his opthalmologist to allow a terminally ill patient who is expected to die soon and who has cataracts in both eyes to have cataract surgery to be able to see his family before he dies.
The story is described at the National Public Radio website
https://www.npr.org/sections/health-shots/2017/12/03/565683105/should-eye-surgeons-fulfill-a-dying-mans-wish-to-see-his-family
Should this decision be subjected to debate as an ethical issue? For example, the opthalmologist involved, who wrote the article, stated:
Our anesthesiologist and others on the operating room team were opposed to performing a surgery on a patient on hospice with only weeks to live. The anesthesiologist was trained in Britain and noted that Thomas' cataracts would never be removed there, where committees decide on the utility of certain treatments and procedures. For someone who would only get a few weeks of "use" out of his surgery, the costs couldn't be justified. Thomas' oncologist was concerned about his health and had a serious discussion with him. However, Thomas understood the risks and decided it was worth it to undergo the surgery.
The title of this thread sets the ethical issue: was the decision to perform the cataract surgery based on the patient's desires simply a matter of palliative care to those terminally ill such as procedures and medications to relieve pain all of which is accepted as ethical medical management? Or could this decision be considered an unacceptable procedure under these clinical circumstances with the only financial gain? Or as the ophthalmologist author asked the reader:
So were we right to perform this surgery? Or were we greedy doctors, only out for the bottom line, driving up the cost of medical care in this country? We see a cataract and need to take it out even though a patient is dying?
So I look forward toward your Comment regarding this unique dilemma. ..Maurice.
Graphic: Google Images
posted by Maurice Bernstein, M.D. @ 9:53:00 PM
8 comments
8 Comments:
Admittedly I am a soft touch for a story such as this particular patient and so I'd of approved of the cataract surgery. The benefit was not just this guy's quality of life in his final weeks but also to his family for many years to come. They can take some measure of comfort in the improved interactions with him in those final weeks and in knowing how happy it made him. Also, the guy was only 58.
Yes doctors do make decisions based on economic gain for themselves. I saw tremendous waste in my in-laws final years and with my parent's final illnesses. With both my mother and my father-in-law we had to tell them to please just let them go peacefully. At the same time patients and their families force much waste on the system. A friend's daughter-in-law is a cardiac nurse at a large hospital and she told me of alzheimer's patients in their 90's that had families insisting on surgeries and treatments in hopes of keeping grandpa alive a little bit longer. Families sometimes just can't let go, especially when someone else is paying for it.
One argument against providing cataract surgery to a patient such as described in the presentation would be "why now?" and not "why not earlier?" Palliative care refers to the relief of pain or distress associated with a medical condition at the time the care is needed and offered. In the case of cataracts, this impairment of vision is a slow though progressive process and one could argue that Thomas (the patient) had ample time and should have had interest much earlier for improving his vision generally and specifically interacting with family, perhaps well before his terminal illness even started and therefore to have had his vision already corrected by surgery.
Would you support this argument against performing this "last minute" surgery> ..Maurice.
I'm curious to know if the patient initially asked for the cataract surgery or if the option was mentioned to him. I'm assuming he did ask for the surgery, based on the statement in the text saying, "he wanted to see his family before he died." I ask this because would we consider this life bettering treatment something that needs to be asked for or something always offered. In other words, should cataract surgery be the norm for palliative care? This could be a significant question based on how the main argument is presented. While the argument looks to weight very much in Mr. Thomas' favor, because of quality of life concerns, the cost counter-argument will dramatically increase ($3000xN) with this surgery being considered the norm for palliative care. For while we might agree that it was ethical for Mr. Thomas to receive this care, will it be ethical for many more patients to receive this care?
Here is the World Health Organization's definition of palliative care with respect to cancer http://www.who.int/cancer/palliative/definition/en/.:
WHO Definition of Palliative Care
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:
provides relief from pain and other distressing symptoms;
affirms life and regards dying as a normal process;
intends neither to hasten or postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible until death;
offers a support system to help the family cope during the patients illness and in their own bereavement;
uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
will enhance quality of life, and may also positively influence the course of illness;
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
As one can read from the above definition, it is not only the ill patient that is to be benefited by the palliative care but also "to address the needs of patients AND THEIR FAMILIES". This raises another factor to be considered regarding accepting or rejecting a procedure weighing benefit (patient including family) vs cost. In the case presented, one could argue that the patient's family and their potential benefit (closer physical-psychological relationship with their dying member) might be also considered in a decision to operate. ..Maurice.
I vote for no cataract surgery, and am suspicious that it was not his request, but his families. If it was his request then the surgery should have been a year or two ago.
My vote is for economic reasons, the same as the British NHS reason.
Also, I understand that hearing is much more important to connecting to people than seeing is. I think deaf people live in a much more lonely world than blind people.
Lastly, consider when Issac blessed Jacob.
Supporting the "lonely world" as characterized by Still Standing (last Comment) is the argument in the review of the book "How Hearing Shapes the Mind" by Seth Horowitz reviewed by Mark Changizi at Newscientist.com titled "Is hearing more important than seeing?"
https://www.newscientist.com/blogs/culturelab/2012/09/is-hearing-more-important-than-seeing.html
Further, biblical support of the view by Still Standing may be found for Genesis 27
at
https://www.biblegateway.com/passage/?search=Genesis+27
..Maurice.
This comment has been removed by a blog administrator.
Corrected post:
I had a loved one that was glad that he wasn't in a socialized system of medicine and had worked hard and had two good healthcare policies for his lung transplant. The medical professionals automatically assumed that he didn't have the funds for the transplant surgery. Then 1 year post surgery the doctors were sending him back to work (assuming that he had social security benefits that would run out and require him to return to work). No one asked him but once they got the info they did state that he was severely immunocompromised and his type of work would put him in severe jeopardy so he was given permanent disability.
About 5 years later he caught the FLU and RSV which progressed his BOS. He was released from the hospital to hospice (but with HIS hope and desire to get better). After this, it seemed that NO ONE listened to him, even as his oxygen needs went from 8 to 2 liters in 2 months. Even when he could talk without SOB and cough. Even when he gained weight and had an appetite.
It seemed like once tracked on "palliative" and "hospice" care it was a one way road. Although he had the means and desire to live (and at least be considered for a 2d lung transplant) NO ONE listened. And then, when he suddenly had his oxygen cut off for 2 hours and the doctors were given a completely wrong history by "loved" ones that he was "one his last breath" for weeks and couldn't even talk, the doctors didn't look further and withdrew his care and gave him morphine and he died. The doctors were very much made aware that the "MPOA" was not making decisions in the principal's best interest and desires and that the MPOA had given the doctors a false medical history. The doctors were begged to please listen to the videos and tapes and emails which supported that he was talking, hopeful and getting better. That his emails indicated that if he ever was intubated, he would want a month to see if there was hope, he was only given 4-5 days. Seems to me, NO ONE cared. He was 53 yrs old.
And if he needed cataract surgery and wanted it and could afford it, I would support it. If he couldn't hear and needed and wanted a hearing aid, I would support it. Yes, I think that options should be given, informed consent as well. It should be presented as "options" and there is a way to state it as such. I saw how the doctor's presented his "options" with euphenisms i.e. "do you want to be comfortable?" He said, "yes, please". He really thought, "would you like me to "fluff your pillow?" In complicated forms, there is something called a Flesch score, I wonder if there is something similar when dealing with a very ill, possibly terminal patient and available options.
Sorry, if this is off subject a little. I just can't believe the course of events that happened here in Dallas, Tx this past few months. It seems like we have become a "hashtag" society.
StilNumbInTexas, HeWantedtoLive, DoctorsShouldSPeakUP
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