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To: flatsville who wrote (53505)	6/9/2000 9:16:00 AM
From: Tunica Albuginea	Respond to of 99985

OT/flatsville, you raise several points: I'll try and be brief: I have personal experience of patients, on Medicare/Medicaid, who where previously cared for at home, who when they ended up in the Hospital, for 3 months!!!* one of the family members clearly told the nurse: "we need his check". Many advance medical directives IMHO are not honored because physicians have a built in incentive to provide as much care as possible. With office visit rates so low, the Hospital is th eonly place a Doc can make the income back up: hospital visits are shorter, the fee higher and procedure fees even higher. I have seen horror stories of *providing cardiac catheterization/baloon/stent on a patient on chronic dialysis who wascompletely demented, age 80, and completely oblivious to the goings on around him; he didn't even recognize his family in the Nursing Home. The last 1 year of his care easily topped $100,000 of which he paid zero. My point simply is: "This Nation does not have the money, ( read: " cannot afford ) to give a $100,000 funeral to every 80 year old dying in America ". I hope this is not difficult to understand. Horror stories such as this abound. TA Message #53505 from flatsville at Jun 9, 2000 8:35 AM ET OT TA-- The figures I have on file are from the mid to late 1990s. These nos. are vastly different from the 1988 study. I think you'll be surprised. I found them alarming...even more so when I consider that hefty percentage of those end of life costs were incurred needlessly...against the wishes of the patient. (I will go back to digging today.) Even if you accept 80% in the last two years of life the trend is clearly rising based on the 1988 study. You mentioned-- >>>It is much more diffficult to implement Advance Medical Directives. I have tries it ( mostly unsuccessfully ), in the last several yearswith many patients. It appears very few of us are ready to die.<<< Is this family intervention seeking to over-ride the AMD of the patient? Unfounded, uninformed fear of reprisal on the part of physicians is cited as a reason for ignoring AMDs: physiciansnews.com "Why Advance Directives Are Not Followed A competent patient?s right to refuse life-sustaining medical treatment is fairly well established by both common law and legislative enactments. While Klavan may present a novel claim in Pennsylvania, patients in other jurisdictions have previously filed suit when their advance directives are ignored. These suits, plus many published research studies on this topic, demonstrate that doctors and health care providers often ignore the advance directives of their patients. Various reasons have been postulated as to why advance directives are ignored, the most frequently cited os which is the fear of suit when a patient?s directives are opposed or disagreed with by family members. In these situations, fearing reprisals from family members, health care providers do not remove life-sustaining treatment unless mandated by a court order. Health care providers apparently adhere to the erroneous belief that they will be subject to a negligence or wrongful death action. This view prevails despite provisions in advance directive legislation, including Pennsylvania?s, that provide immunity to medical professionals who participate in the withdrawal of life sustaining treatment pursuant to an advanced directive." I find this hard to believe: >>>Also there is the issue of the Social Security check: families are loath to let grandpa's check go. So they keep him going; on the ventilator; on dialysis; with enteral tube feedings; in the Intensive Care Unit; in the wards; in the Nursing Homes.<<< We both know that the monthly cost of long term care for those not indigent far exceeds "grandpa's" Social Security check by thousands of dollars. We also both know that those indigent patients admitted to long term care under Medicaid never "see" their Social Security checks again (nor do their familiies) as it is applied directly to the cost of their care. There are very strict limits regarding the amount of money an indigent patient is allowed to hold in his or her name...far, far below the monthly Social Security payment...and usually just enough to pay for the cost of incidental items. While it may appear there is a "greed" factor in keeping grandpa alive against the wishes expressed in his AMD, it simply doesn't wash. I believe there are much more irrational, emotional considerations operating. And then there's the issue that many AMDs are simply ignored by the medical staff: sciam.com note: "Less than half of the physicians whose patients had signed orders forbidding cardiopulmonary resuscitation were aware of that fact. During the second phase of the study, each patient was assigned a nurse who had been trained to facilitate communication between patients, their families and physicians in order to make the patients' care more comfortable and dignified. The intervention failed dismally; the 2,652 patients who received this special attention fared no better, statistically speaking, than those in the control group or those in the previous phase of the investigation."