Very Interesting!

[galvo]

When it is time to say enough December 6, 2010
 Sydney Morning Herald
 
Source: Royal College of General Practitioners, UK.
For some elderly patients, dialysis is not worth it, writes Julie Robotham.
Only one therapy has any real chance of prolonging the lives of Mark Brown's patients, and he usually prefers to talk them out of starting it.
Dialysis may, in a sense, save the lives of people with advanced kidney disease.
But in Professor Brown's observation, for the elderly it is most often simply not worth the price of relentless hospital visits - usually three a week - and their burden of physical and emotional distress.
He has come to believe the alternative of keeping people comfortable while their kidney failure brings about their eventual death is ultimately better for many, if not most, people in that predicament.
"When you've got a technology available, the normal response is to use it," said Professor Brown, a renal specialist at St George Hospital, of the dialysis machines now used to filter the blood of more than 10,000 Australians, at a cost approaching $1 billion.
By making explicit the option not to use the technology, and formally acknowledging a natural end-point for active therapy, Professor Brown has put himself and his patients at the centre of a gathering debate: where to draw the treatment line for the growing number of people who avoid cancer, stroke or heart attack, but still face inevitable death from the progressive failure of one of the body's essential organs.
For older people, who, in addition to their struggling kidneys, usually have other medical problems, any benefits from dialysis may simply be too marginal and the residual chance of dying too high to justify the personal cost.
"If you're over 75 in Australia and you go on dialysis there's a 25 per cent death rate in the first year, and [an additional] 25 per cent in the second year," Professor Brown said.
"It's invasive and a very great imposition on people's lives. Over 10 years the quality of life for people on dialysis has improved only slightly."
Professor Brown has pioneered the state's first renal palliative care unit, for those who forgo dialysis, withdraw from it, or are too sick to start. Three-quarters of his new patients have never tried dialysis.
"This has become one of the most rewarding parts, paradoxically, in my 30 years as a doctor," Professor Brown said.
"Our training has always been about keeping people alive. It's less about dying with dignity. When [patients] die it's still tough because you've known them a long time. This is a great service and a positive service but it's never going to be easy."
Symptoms such as severe itching can be treated with medication. When death finally comes, it is relatively gentle. "You'll drift off into a coma and you won't be aware,'' Professor Brown said. ''One of the blessings of the renal death is that it's not a painful death."
The program comes amid a surge in dialysis treatment of the elderly. The annual number of new dialysis patients in their 80s nearly doubled between 2004 and 2008 - the fastest growth of any age group.
Of 792 patients who began dialysis in NSW in 2008, a quarter were aged 75 or older, and 19 were older than 85. By contrast, over the same period in New Zealand fewer than 10 per cent of new dialysis patients were older than 75, and nobody over 85 entered the program.
People who had heart, lung or vascular disease in addition to kidney failure did not extend their lives by entering dialysis, Professor Brown said. But faced with a choice, patients and families might still feel coerced to have treatment.
"Over my years I've developed the approach of trying to guide the patient more forcefully to a decision [not to enter the program]''.
Despite the high cost of dialysis - about $75,000 a year for each patient - Professor Brown said he had never been asked to restrict treatment of the elderly. But "all this technology is going to increase the national expenditure and at some point some leader is going to have to lead a debate about more appropriate selection of patients … It's not a discussion about money.
''It's about the wellbeing of individuals."
Bruce Pussell, a renal specialist and professor of medicine at the University of NSW, said families sometimes resisted advice that dialysis should cease.
''They say, 'You're killing them' and then we say, 'No we're not; the disease is killing them'. We would face that sort of thing 10 or 12 times a year.
"The rise in the dialysis rate has to reach a peak. It can't go on forever."

Discuss

[Stoday]

Looks like it's curtains for you, Galvo. 

Bruce Pussell, a renal specialist and professor of medicine at the University of NSW, said families sometimes resisted advice that dialysis should cease.

Better not ask the patient, he might resist the advice even more...

I note the convoluted reporting of an Australian issue, in a UK GPs' magazine, picked up by a Sydney newspaper. 

[Des]

This is so true!!!

I went shopping on Saturday and ended up on my usual midway bench "while the rest of the family shopped" When I saw and old skinny and frail man with a cain. I noticed the telltale signs of the 2 plasters on his left fore-arm. Yep, he was on dialysis for 5 months.

He said  that he can't see the point of doing it ... he has so much wrong with him and he really don't see why he has do to this 4 times a week. He is doing it to please his wife. He is ready to go to his God... I just smiled knowingly and have been wonderiing about this question eversince. When is it time to call it quits? Should age be the cut-off or should the pasient decice. If they leave it up to the family - it could go on for years.

Just wondering.?  

[Bruno]

I live in Sydney and to a degree the report is true, but it takes a rather broad view of what is often a specific issue. Firstly, I think we are all given the option of going on dialysis or refusing it. I don't think that point is made clearly enough in Professor Russell's article. At least that is the case at RPA which is the leading renal clinic in NSW. On the other hand there are plenty of older people who I see and I do not think should be on dialysis, but I also see just as many for whom dialysis is a godsend for them and their family.
By the way, I am 75 and hope to put at least 5 more years on dialysis.
The average life expectancy for an Australian is 84, advances in medicine have made this possible including advances in dialysis. My doctor tells me however that the biggest advances have been made in the treatment of heart disease and it is this that has pushed the death age figure up significantly...the statin drugs for example.
Our medical care is free in Australia to people my age and all those in need so to speak of cost for a particular treatment is not quite accurate...for example open heart surgery is hideously expensive, so are we to limit it to those below a certain age? If it is to be 70 I would not have had mine 5 years ago.
There is a huge debate going on in this country about euthanasia, but I don't think the way to approach that is by setting limits on medical care, most of us as we grow older would rater be told there is no more to be done rather than have it occur as a result of a government review of service.

[paul.karen]

Kinda funny how medical advances have made us live longer in general.
And now that we have the technology to help people live longer many would prefer that the people just die away.

In the near future there will be panels call them death panels or just panels it will be people who decide who and at what age treatments will be given to people or declined to people.

Funny how in the US. the one person who was compassionate about letting people die a dignified death at there own free will is sitting in prison.  This man didnt decide who should die or when they would die.  he just helped them die if they were in the right frame of mind to make the decision and only if they had a terminal disease.
Dr. Kevorkian a man ahead of his time.  Looks like now we may not have the freedom to choose but rather the facts of being told or just being denied medical care due to age or progression of a disease.  I wouldn't want to play god and decide peoples fates.

[MooseMom]

But paul.karen, right now it is my insurance company that serves as a "death panel".  Blue Cross Blue Shield decides if they are going to allow me access to new expensive technologies or new expensive medications.  I have to ask them for permission to be tested to get on the transplant list.  I have to ask their permission to have my gallbladder removed.  I have to ask their permission to have my fistula created.  Any time I have to get a "referral", it is actually theirpermission I have to acquire.  THEY get to decide whether or not I get this treatment or that medication.  These death panels are already in place, and their decisions enable them to acquire profit.

I don't have the freedom to choose a damn thing.  Since I have the dastardly "pre-existing condition", my punishment for DARING to be sick is the removal of my freedom of choice.  I have to have doctors chosen by BCBS...I can't see any doctor not on their stupid list.  Where is MY freedom?  I have to sacrifice MY freedom of choice for THEIR profit.  It's unAmerican and approaches fascism, in my very humble opinion.

I think we have a long way to go in allowing people to make their own choices about how to die.  That Dr. Kevorkian is in prison can be blamed upon the ultra-religious in this country who believe that ONLY GOD can decide who lives and who dies, when and how.  According to the "Christians" in this country, you don't get the freedom to choose how you die.  If He wants you to continue to live and suffer horribly, then that's His will and it is not Dr. Kevorkian's place to help you in what you think should be your choice.  (I agree with you to some degree about Dr. Kevorkian, and I think that with certain guidelines, a doctor should be able to help you die if you choose, but I'm just telling you what was the religious argument against it, and it is upon this sentiment that the law was written.)

This really shouldn't be a discussion about whether or not the elderly should go on dialysis.  It should be about whether or not the already very ill elderly should go on dialysis, particularly if they themselves don't want it.  Like any treatment, each patient has to decide whether or not it is "worth it".  Other family members should guilt people into D.  This really should be a discussion about how to allow family members to let go and not subject their elderly loved one to painful and difficult treatments of ANY kind.  Quality of life has to be examined.

[paul.karen]

The patient does have the right to refuse Dialysis or Chemo or any other kind of treatment.  We have had several here with parents who quit dialysis and told the experience on a daily basis.

What i dont like is the idea of a panel of people saying well if your X years old you wont be allowed to go onto dialysis or be allowed chemo.  I can say with certaintiy that not all 80 year olds are the same.  Some or very sick while others are likley more acitve then many our age and younger.  But a panel wouldnt see this they would just go by guidelines.

As for Christians as with any group or religion there are the moderate and the extremists. Me and my three brothers pulled the plug on my mom so to say.  Hardest decision we ever made but she was uncurable.  And the only reason she was even on life support was in hopes all her sonswould make it to Seattle to say goodbye.  IM a chrstian?  does this mean im going to hell?  Or that i sent my mom to hell?  We have to make decisons based on a peson to person scernerio. 

As for your insurance.  Well i know you are all for full government healthcare.  One payer system ect ect.  Or at least i think your for that.  I prefer not to rely on the government for most things.  Least of all to be able to run a healthcare system that would funtion.   But thats me.  I realize many think the government should run healthcare.

Many think the government should take care of them from cradle to grave.

[greg10]

...
As for your insurance.  Well i know you are all for full government healthcare.  One payer system ect ect.  Or at least i think your for that.  I prefer not to rely on the government for most things.  Least of all to be able to run a healthcare system that would funtion.   But thats me.  I realize many think the government should run healthcare.

Many think the government should take care of them from cradle to grave.

I don't think most people in a democracy expect government to take care of them completely.  However, government should be there to provide a standard of care that is expected of a civilized society.  Without such standards, market forces will run amok and when it comes to health care cost where your life and health is at stake, the sky will be the limit if it is purely profit driven.  People want to have a choice that can counter the market forces, and that is what a government should stand for.  Democracies around the world have shown that some level of government regulation and participation in the health care system is required to bring down cost and provide generally better care for all their citizens.  If you have read this month's issue of the Atlantic Magazine (Dec, 2010) you can see that the US has one of the worst first year mortality of patients starting dialysis in all of industrialized societies.  A large part of that is due to the grip that big businesses (clinics, drug and insurance companies) have on the dialysis health care business.
http://www.theatlantic.com/magazine/archive/2010/12/-8220-god-help-you-you-39-re-on-dialysis-8221/8308/

“God Help You. You're on Dialysis.”
Every year, more than 100,000 Americans start dialysis. One in four of them will die within 12 months—a fatality rate that is one of the worst in the industrialized world. Oh, and dialysis arguably costs more here than anywhere else.

[MooseMom]

paul.karen,  Of course I don't believe you are going to hell or that you've sent your mom to hell.   I believe as you do, that it is humane and "Christian" to relieve suffering.  I'm just reiterating what drives some of those who are against Dr. Kevorkian's beliefs.  It doesn't mean that I agree; I'm just showing how the personal beliefs of one set of people can unfairly mean foisting those beliefs onto people like yourself who are trying to do the right thing by showing compassion to someone who is dying.

I really don't think that anyone is suggesting that people over the age of X should be denied treatment.  Maybe what IS being suggested is that people over the age of X who have multiple organ failure not be treated aggressively but, rather, pallitively.  Perhaps what we all need is to have a discussion about  what TYPE of treatment is appropriate and what the goal of that treatment is.

You and I are in basic agreement; it's just that we perhaps define "death panels" in a different way.  We both are greatly opposed to any third party imposing upon our freedom to make our medical choices.  I don't particularly want government running healthcare although you have to admit that Medicare does just that for those on dialysis and for those over 65 AND for those in the VA system.  So, "government run healthcare" is already here and has been for many years.  While you don't want government running healthcare (and I can understand why), I don't want profit-making corporations running it, either, but they do.  Ironically, what you and I do not want is irrelevant because those models already exist.

Interestingly, dialysis falls into both categories.  If you are lucky enough to have access to private medical insurance, then a major profit-making corporation is overseeing your treatment.  Your doctor can order whatever he wants, but if your insurance company decides his treatment preferences are somehow undesireable, then they are not going to pay for it and chances are, you won't get it.  After 30 months, your private insurance decides they've had enough of you costing them so much money, so you are handed over to government-run healthcare/Medicare.  None of this seems to be in the patients' best interest, and none of this seems to ensure that patients have any choices.  I don't see why our healthcare has to be an either/or proposition.  So while I was unsure about the single payer plan (although I've been a patient on the NHS in the UK and liked the care I got), I did support the public option because it was an OPTION, and I thought Americans liked having OPTIONS.

I don't like having to rely on one's employment for access to healthcare.  If you change jobs, your access to health insurance is impacted.  The cost of providing health insurance is an obstacle to business, especially small businesses.  I don't see why we have to saddle businesses with an ever increasing financial burden.  It is hard to start a business when you have the bureaucracy of providing healthcare access to your employees; it seems like such a disincentive right when we need MORE incentives to start MORE businesses to fuel a very sluggish economy.  Having to rely on our employer for health insurance robs us of our freedom to find employment in jobs that might be more suited for us.  Again, I'm talking about ROBBING us of freedom and choice.  The present set-up is positively unAmerican.

I agree with greg10 that most Americans don't expect the government to take care of them from cradle to grave.  But we have to ask ourselves what we, as a society, do with/for people who cannot take care of themselves for a period of time.  How much of a safety net do we decide to provide for our fellow citizens?  What do we do with/for all of the people who are out of work and who now have run out of unemployment benefits?  Do we just declare all of them to be simply lazy and undeserving of help?  I don't know...maybe we do.  We claim to be a Christian nation...how many American Christians would willingly support a family of four whose parents are out of work because the companies they work for no longer even exist due to the current recession?  Do we as a society agree to stop financial support and rely upon the charity of our communities?  Would enough Americans step up to this task?  Or do we agree to pay our taxes and declare that that money is to go to our fellow Americans who have fallen on hard times?

[paul.karen]

I think we do agree on alot of issues.  I have a hard time expressing myself on a computer so kudos and thx for seeing through my not so suave approach to what i mean to say and what comes out.

IMO healthcare will only get worse and burdened down.  Without a doubt we needed to change the status quo but me and about 70/80 % of Americans arnt to happy with the obama plan.  Companies are now letting go private insurance cause it is cheaper not to insure there employees.  I think this was a built in fact the Obama people were counting on.  It brings them one step closer to a one system payer system.
This plan anyway you l0ook at it was Forced upon us.  Backdoor deals money to certain states to get a vote ect ect.  I know this is Washington as usual but this is a BIG DEAL with real lives and consequences.  Only time will tell.  Remember what pelosi said.  If you wanna see whats in the bill pass the bill. 

They are changing (instead of fixing) healthcare for the minority of people who didn't have healthcare.  Which is fine.  But to take money from medicare which deprives the elderly or people on dialysis and to change things that people were happy with for a system that is unproven is crazy.  The cost of this is going to have major overruns just like medicare social security and everything else the govt. touches.  It would have cost billions less to just have put 30 milllion people into a private healthcare plan then what this will cost in the long run.

Not to mention out of the 30 million uninsured how many millions could have been insured from work or have paid out of pocket if they wanted to.  Not everyone wants to be forced to buy insurance.

We could have fixed the problem in a different way.  But Obama owed his progressive party who got him in office.  Funny how they didnt even touch on medical malpractice which is one of the biggest cost factors.

I hope on wrong and all will have the best medical available.

[MooseMom]

I think one of the more interesting philosophical debates is whether or not we should be forced to pay for insurance.  Like most Americans, I don't like the idea of HAVING to pay for anything.  But insurance is a different thing altogether.  It is actually socialist in nature.  It is based on the idea of pooling resources in order to minimize risk for that pool.  It is the ultimate in cooperative behaviour.  Ideally, one should be able to choose whether or not to cooperate.

The problem comes in deciding what to do with those who decide NOT to cooperate but then find themselves in situations where they need the support of the pot.

Sure, you can self insure, ie, buy your own private policy, but in doing that, you lose the protection inherent in group purchasing power.  I bought my own individual policy back in 2003.  I got sick and was hospitalized, and my insurance company denied all of my claims and revoked my policy.  Bottom line...I was able to exercise my freedom of choice, but the unintended consequence was that I was alone and lacked the power of having a group behind me.  This is why we hear more talk about "pools" instead of hearing about a push for people to just by their own stand-alone plan.  It's all about spreading risk.  The idea is that the more people in the pool, the smaller the risk to each individual AND the smaller the expense/premium.

Do we ask our doctors to deny treatment to people who have chosen not to buy insurance? 

Do we force insurance companies to insure people who are already sick and who are not "cost-effective"?

Remember that health care does not work like other markets.  We don't choose to get sick, and we don't get to choose our treatment based on price.  We often don't even know the price of this test or that test.  When you're sick, you shouldn't have to shop around for the best medical care at the cheapest price.  So, the whole concept of "choice" when it comes to health care is often just a paper tiger...it doesn't really exist.  The discussion about who should be forced to do what and for what reason is an interesting one.  I personally feel that anyone who might possibly at one time need health care should be required to contribute, and that's pretty much all of us.  It's a stand off between "rugged individualism" and "it takes a village."  I think we should all exercise personal responsibility and contribute to the pot by buying health insurance to try to ensure that everyone has access to at least minimal care, but that's just me.

[galvo]

Thank you for your kind thoughts, Stoday! The Herald is doing a series of articles on death and stuff. Hence the convolution.

[Bruno]

MooseMum, I don't want to upset you but I think the debate on Euthanasia spans a wide divide...I am a humanist (atheist, if you like) but I have concerns about it as a law that binds people to a course of action. So I don't agree with where the Christians are coming from, but I do agree with where they are headed.
I don't feel it is my place to comment on the business of another country that I believe is a credit to humanity and the world's best bet for a peaceful planet but you really have a health program that is in a real mess...it does not appear to help those who need it most.
Their is no reason at all why private insurance and public health care systems cannot operate side by side and as for having your employer pay your medical insurance, why that is madness.

[RichardMEL]

Very interesting question. I think it should come down to each individual and what THEY want - what THEY see the quality of their life as being either with or without dialysis. We all know hiow difficult and stressful D can be on your body and the associated conditions (eg: bone dease, secondaryhyperparathyroidism, etc) and to some it may not be woth it. To others with a love and vigour for life the pain and effort may be worth it to continue spending time woth their families, and doing things they enjoy. If you see no quality with dialysis then might as well decline it. Definitely a situation where one size does NOT fit all.

Like euthanasia I think this is one area that needs more open discussion and understanding in the community that denying dialaysis doesn't have to be the act many see it to be, and that there can be very understandable and reasonable reasons for making that decision. Like my mum always said she never wanted to be "propped up" by a machine if it meant she had no quality of life - for her, there's no point (in that case she was talking about a ventilator, which is an extreme example). When the time came she stood by her decision, and we supported her because she had always felt that way.

[MooseMom]

Bruno, far from upsetting me, I agree with everything in your post.

[cariad]

I have not read all of the responses, so forgive me if this is repetitive.

Please do not read if you want to see the film You Don't Know Jack because this will ruin it

Dr. Kevorkian is not in prison - he was released in 2007.

The god botherers were not responsible for putting him in prison, but they did make his life a misery by protesting every single day outside of his house until his solicitor paid to move him to an undisclosed location. Dr. Kevorkian was put in prison by a shouting mad judge who incarcerated him for the sole reason that he broke the law. Laws in Michigan were changed specifically to stop him, but the local DA made a deal with Jeffrey Fieger (attorney) to leave Kevorkian alone, and the film portrayed the DA as being somewhat exhausted by continually losing cases to Fieger.

Then Dr. Kevorkian decided to step his work up a bit by injecting someone himself rather than rigging a device that would allow the person to do it for himself. He then announced this to 60 Minutes, which is a huge "I dare you" move on his part. They dared, and they won. This is not to say whether it was right or wrong. The film was exceedingly sympathetic to Kevorkian while also being honest.

You can indeed legally kill yourself in the US if you have a terminal illness. I have read up on this extensively because for my job at the suicide hotline, people always had questions about this and I wanted to be able to answer their enquiries intelligently, with the focus always being on preventing suicide, of course. (These were profoundly depressed people - I never tried to convince an individual to continue treatment if the person was terminally ill.) In the state of Oregon, in order to receive a prescribed suicide pill, one must reside in the state for 30 days prior to visiting a physician for a full exam. Family will also be consulted and need to give their consent, but I do not remember the details of that. I am glad this choice is available, though I wish it were nationwide.

In Britain there was a devastating case of a woman with I want to say MS who was losing her mobility. She wanted permission from the government to go to Sweden and if I recall correctly return to Britain and have her husband administer the fatal dose once she had become completely paralysed. She wanted assurance that her husband would not be prosecuted, and last I heard they denied her request and her response was "You're forcing me to kill myself before I am ready to die." A thorny set of circumstances if ever there were one.

I agree with Richard that we need to listen to the person suffering. In the film, not one person hesitated an instant before triggering the suicide. The questions Kevorkian would ask of patients made me become sentimental and want them to choose to live, but then the fact that not one of them had anything but the clearest vision that death was the right path for them speaks to the incredible agony that they were suffering and that those of us who live without that pain can not fully understand.

I want socialized medicine for the US. I think anyone that does not want that for the country should not accept it for themselves and therefore turn down Medicare. I hardly want the government to "take care of me" but by the same token, by this definition I don't want a corporation to "take care of me from cradle to grave" either. That is indentured servitude - continue to work for us or we rip away your healthcare. It is a stupid system, the results are pathetic as we fail miserably in comparison to many other Westernized countries, and our health system should be a national embarrassment. Bruno, absolutely right, it is madness.