Patients have the right to decide how they will die. But lacking medical training and experience, they need the advice of their physicians in order to make the best possible decision. No family member can supplant this, regardless of how well meaning they may be. I believe my patient's daughter did him a disservice, subjecting him to a battery of invasive and noninvasive procedures that in the end had no impact on his quality of life or life expectancy. (As one of my attendings was fond of saying, "Beware the daughter from out of town.") As for the cardiovascular specialists who recommended these procedures, only to decide in the end that he was not a surgical candidate, I can only say that the patient and I had reached the same conclusion months earlier.
Friday, August 14, 2009
"Funny the way it is, if you think about it..."
In the "debate" over end of life discussions, neither party has it right. The Democrats have proposed payment to physicians when they perform this task (presumably because they believe it will reduce health care costs in the long run), while the Republicans have invoked the specter of a "death panel" and insisted that these decisions should be left to the patients and their families. Under the current fee for service model of health care, I am paid for the actual work I do, whether that work involves a consultation, a diagnostic study, an invasive procedure, or a follow up visit. I have always viewed end of life discussions as an ongoing narrative rather than a isolated piece of work. They are an integral part of what we as physicians do in caring for elderly patients with a deteriorating quality of life and dwindling therapeutic options. The octogenarian described in "Second Opinion" had been seeing me for quite some time, and we had had frank discussions about his prognosis and his wishes over the course of many hospital and office visits. Unlike the hospitalist who works an eight to twelve hour shift, meets patients for the first time when they are admitted with an acute illness or progression of a chronic condition, and does not see them again in follow up upon discharge from the hospital, I am able to develop long term relationships with my patients that afford me a unique perspective on their care. Carving out the end of life discussion (and reimbursing me for it) as an entity separate from the rest of my daily routine is unnecessary and awkward.