More senior citizens are dying at home - Miami-Dade - MiamiHerald.com

By John Dorschner

jdorschner@MiamiHerald.com

After years of experts and patients saying people at the end of life might be more comfortable dying at home, a new study says that may finally be happening: fewer seniors in the United States and South Florida are dying in hospitals.

But the same survey finds that in the last months of life for seniors throughout the United States and especially in Miami, the trend is for more of them to see large numbers of specialists and to spend more time in expensive intensive care units.

Those are the results of the latest study from the Dartmouth Atlas, a project of the Dartmouth Medical School. The project for years has been using Medicare data to expose anomalies in healthcare costs and wide geographic disparities in expenses.

“Miami is practically off the charts,” says David Goodman, a Dartmouth researcher who was the lead author of the study. “It really continues to stand out” for having the highest costs and most extensive treatments in the last months of life, even when adjusted for age, ethnicity, race and severity of illness.

via miamiherald.com

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Patients with do-not-resuscitate orders fare worse | Reuters

A new study could help people with a do-not-resuscitate order make better decisions about what surgeries they are willing to undergo.

About seven in 10 Americans die with such an order, which instructs healthcare workers not to use life-prolonging treatment if a patient's heart or breathing stops.

But other situations that aren't necessarily covered in the do-not-resuscitate, or DNR, orders may also be worth considering, researchers say.

The new report, out Monday in the Archives of Surgery, shows DNR patients have a higher chance of dying following surgery, although not with all kinds of procedures.

via reuters.com

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This American Death: The Movie

How has the pursuit of a good or natural death been altered by advances in medical technology which now can almost always extend life, if only for a few minutes, hours or days? Who does not question their Do Not Resuscitate order with death staring them in the face? How can doctors be expected to manage death when they receive so little end-of-life training? And where can a person go to die in peace, if they have no family and do not want to endure hospital procedures?

This American Death explores the complicated world of death and dying in contemporary America, examining the cultural and systemic issues which conspire against Americans experiencing a so-called good death. Despite the consensus that exists among Americans about how they wish to die - surrounded by loved ones, pain free and relatively unaided by technology - why do so many still die in hospitals, in pain, supported by machines? The film looks at why, when a good death is seemingly achievable, few actually experience one?

via thisamericandeath.com

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The care was futile, and the patient's wishes, KevinMD.com

by Jim deMaine, MD

“We have a patient on a ventilator here who is stable enough to transfer to your ICU, if that’s OK with you.”

This call, coming from the transfer coordinator, is emblematic of an insurance generated “medical care” coverage issue. I am salaried under the patient’s insurance carrier so the insurer wants this patient back under its wing as soon as possible.

The community hospital has been keeping Stella Norris (not her real name), an 89 year old woman, as long as possible. She is incapacitated from a massive stroke suffered five years ago. There is a feeding tube inserted through the stomach wall and she has needed total body care. 911 was called when she stopped breathing and she was taken to the closest hospital.

via kevinmd.com

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Discussing cancer treatment with the terminal patient, KevinMD.com

“Are you giving up on me?” My patient looks at me severely. “There must be other treatment options! Aren’t there some experimental drugs out there? I have beaten this cancer twice before. Are you saying that I can’t beat it again?”

No one can ever know with absolute certainty whether my patient’s newly recurrent cancer might miraculously disappear with one more treatment. His recurrence, however, has developed very quickly and is growing very rapidly. New cancer nodules are developing weekly. I have never seen a patient with a cancer this aggressive have a meaningful, sustained response to further treatment. The research literature confirms my impression.

It is always difficult to know what to recommend. Although “no further treatment” is always an alternative, I routinely run through all of the options, reviewing whatever is available, and hoping that we land on the combination that offers that improbable, one-in-a-thousand cure. However unlikely, we sometimes set up appointments and hope for the best.

Today, though, my sense is that it is time to focus on new goals.

The decision not to pursue more studies and more treatment can be very, very difficult. Surgeon and journalist Atul Gawande in an essay in The New Yorker entitled “Letting Go,” writes about how difficult it can be for physicians and patients to halt cancer treatment as the end of life draws near. The dilemma, he concludes, “arises from a still unresolved argument about what the function of medicine really is — what, in other words, we should and should not be paying for doctors to do.” In Gawande’s view, the profession should equip and supply doctors and nurses “who are willing to have the hard discussions and say what they have seen …”

via kevinmd.com

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Death in a hospital is not always comfortable, KevinMD.com

In America, too many people die in the hospital.

I don’t mean that they die due to medical error or incompetence, though that’s always a hot topic of discussion amongst doctors, researchers, administrators, and regulators.

What I mean is that if you ask most people, they say they’d rather die at home, surrounded by their loved ones, drifting off to sleep painlessly after having had last rites administered (feel free to plug in your religious/atheistic ritual of choice here).

Why, then, do so many who want this type of death instead die medically, here in the hospital, undergoing painful treatment and the deprivations and degradations of medical care?

The answer has both simple and complex aspects. But I’ll start by sharing something that most medical professionals believe:

When my time comes, the last place I want to be is in the hospital. Don’t get me wrong–I like GlassHospital–it’s a good place to work, teach, and learn. But when the grim reaper is calling my name, I want to be as far away from here as I can.

No IVs. No needle sticks to test my blood. No waking me up to check vital signs every shift. No hospital food. No fluorescent lights.

No feeding tubes; no bladder catheters (ouch!); for Heaven’s sake, no breathing machines (‘mechanical ventilators’).

via kevinmd.com

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