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Forbes website has a piece discussing the reasons our health system spends more on End-of-Life rather than on the young.  It lists 6 reasons.  I want to just state before delving into some of the reasons that I am not discussing this from a political point of view so much as a human point of view.   

The reasons are complex and varied and sometimes it is for several reasons.

1. Natural human tendency to preserve life, especially of a family member or loved one. End of life is not an easy or happy time and no one takes pleasure in making the decision of ending a life.

I believe this first reason to be at the core of the issue.  The hardest thing for someone to do is say goodbye, especially when it is “permanent.”  As such, it makes perfect sense that the financial challenges would partially fall into the category of the challenge of letting go.  And I believe whole-heartedly that we cannot deny the human element in “treating” the untreatable. 

2. Unrealistic expectations of modern medicine to achieve a cure, especially in some patients with cancer, post-cardiac arrest, end-stage cardiac or pulmonary disease and major stroke. 

The notion of hope is not rigid for people.  And if we didn’t have a sense that medicine would cure, we wouldn’t be where we are today, because why bother researching to cure more diseases.  Yet, this is where sound education can also play a role.  Do doctors educate their patients before they reach this stage or do they merely build up false hopes to allay their own sense of failure?  I am not using this as a platform to attack the medical profession, but rather to reexamine elements of the question.  Truth is, this second reason is in a certain sense merely a continuation of the first. 

3. Politics. Remember the unfounded concerns re: government ‘death panels’ and the inappropriate intervention by our Congress re: Terry Schiavo.

http://en.wikipedia.org/wiki/Ter…

The political fears are more related to the misuse of power.  People were afraid of walking down the road were it is merely an “objective” body deciding when life should end.  We who espouse the belief that it is in G-d’s hands at the very least do not want inteference from Government bodies to decide when life should end.  Having said that, it is important that discussions be had to prevent the costliness of certain unnecessary medical situations.  If people were more involved in making informed decisions before facing crisis, perhaps the question would not even come up of government determination. 

4. Guilt. Family member who hasn’t seen patient for years now wants everything done.

In the category of not being able to let go, this one is among the most prevelant.  If one is so afraid of guilt, then be involved before it is too late. 

5. Incentives. Not uncommonly, it is easier to just do every test and provide every procedure without bothering with thought or discussion as to whether the intended intervention is appropriate. Plus, current CPT coding allows a higher payment to a practitioner who orders a test or prescribes treatment.

My best example in this regard is personal. My father, who was dying and who had an obvious stroke, was placed in Hospice by our family. Before leaving the hospital, the nurse went to take him to the CT Suite for a brain scan. When I asked why, she said his doctor wanted to confirm that he had a stroke. I quickly informed her that it was obvious that he had a stroke and that a CT would not affect his treatment or outcome in any way. The scan was cancelled and we took him home for comfort measures.

I think this fifth reason is pretty self-explanatory.

6. Legal. No one wants to get involved with a malpractice case due to denial of treatment, especially if there is no living will or if there is conflict among family members as to what they want done.

And this is where many of the problems tend to lie.  The fear of being sued is so strong we overwork the system to prevent the legal battles.  Perhaps, this is a good area to start reform.  This reform includes family education as well as doctor’s need to justify the need for more unnecessary testing.

All in all, a very comprehensive list.  The dilemna of how important distributive justice is in making ethical decisions is shifting.  The topic of monetary and fiscal value is becoming more important as time moves forward due to the decrease in resources all over.  Yet, if we remove the human element of health care, we might be left with an even more unfeeling system than we have currently.

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