What can we do about death? Reinventing the American medical system

From the 31 May 2011 Eureka News Alert

(Garrison, NY) In a feature article in The New Republic,(subscription only, check your local public library for availability)  Daniel Callahan and Sherwin Nuland propose a radical reinvention of the American medical system requiring new ways of thinking about living, aging, and dying. They argue that a sustainable—and more humane— medical system in the U.S. will have to reprioritize to emphasize public health and prevention for the young, and care not cure for the elderly.

An interesting twist on their argument, which would aim to bring everyone’s life expectancy up to an average age of 80 years but give highest priority for medical treatment to those under 80, is that Callahan and Nuland are themselves 80 years old. Daniel Callahan, Ph.D., is cofounder and president emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Sherwin Nuland, M.D., is a retired Clinical Professor of Surgery at the Yale School of Medicine and author of How We Die and the Art of Aging. He is also a Hastings Center Fellow and Board member.

“The real problem is that we have medicine excessively driven by progress, which aims to rid us of death and disease and treats them as the targets of unlimited medical warfare,” said Callahan and Nuland. “That warfare, however, has come to look like the trench warfare of World War I: great human and economic cost for little progress. Neither infectious disease nor the chronic diseases of an aging society will soon be cured. Cancer, heart disease, stroke, and Alzheimer’s disease are our fate for the foreseeable future. Medicine and the public must adapt it to that reality, one that has mainly brought us lives that end poorly and expensively in old age.”

The article notes that the Affordable Care Act might ease the financial burden of this system, but not eliminate it. It reports, for example, that the cost of Alzheimer’s disease is projected to rise from $91 billion in 2005 to $189 billion in 2015, and to $1 trillion in 2025 – twice the cost of Medicare expenditures for all diseases now.

“We need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person,” the authors write. “An old age marked by disability, economic insecurity, and social isolation are also great evils.” They endorse a culture of care, not cure, for the elderly, with a stronger Social Security program and a Medicare program weighted toward primary care that supports preventative measures and independent living.

Callahan and Nuland point the way to a more sustainable path that reprioritizes the entire system. Among their recommendations:

• improve medicine at the level of public health and primary care, while reducing its use for expensive high-tech end-of-life care;
• shift resources for the elderly to greater economic and social security and away from more medical care;
• subsidize the education of physicians, particularly those who go into primary care, and decrease medical subspecialization;
• train physicians better to tell the truth to patients about the way excessively aggressive medicine can increase the likelihood of a poor death;
• shift the emphasis in chronic disease to care rather than cure;
• conduct a top-down, bottom-up, long-range study of the entire American system of health care, including the training of physicians, with a view toward reconstituting it along systematic lines that take science, humanistic concerns, economics, and social issues into account.

Related articles

• Andrew Reinbach: Health Care Could Kill Us: We Don’t Have to Let It (huffingtonpost.com)
• New at Reason: Ronald Bailey on Health Care Reform (reason.com)

“Summaries for Patients” and other plain language summaries help patients and others understand medical studies and guidelines

Heard or read about research on a medical topic but not sure if the news is reliable? Looking for trusted information on a treatment or drug carefully reviewed by experts? Do scientific articles seem to contain good information, but they are hard to understand?

Not sure where to go next?  You are not alone.

These plain language summaries are great places to start for medical and health information that has been rewritten for those of us who are not scientists or health care professionals. Much of the information is free, and often there are great links to reliable Web pages for additional information.

• Summaries for Patients  are short plain language summaries of medical research and guides for doctors.

                    These summaries will help you

• Discover how researchers did the published study and what they found, including
  • What the problem was and why it is studied
  • Who was studied and why the study was done
  • What the scientists found and what the limits of the study were
• Find overviews about clinical guidelines -official recommendations for doctors in treating patients

To locate a specific summary

• Go to Patient Information
• Follow the directions under the Summaries for Patients heading

•  patientINFORM plain language summary Web sites  are provided only by participating science and medicine publishers.

These summaries are provided to help patients or their caregivers more fully understand  research results. They also provide links  to the full text of  many research articles.
Some full text articles are free. Others require a reduce-fee payment (much less than ordering from the publisher!).
(Always check to see if you can get the article for free or at even lower cost from your area public, medical, or academic library – most libraries will try to help anyone who contacts them directly)

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

• Cochrane Collaboration provides well researched reviews of the strongest evidence available about healthcare interventions (as drugs, medical tests,  and medical procedures).  Every available treatment/test has not yet been reviewed. However each review is conducted in depth by experts.            

              To find plain language  and audio summaries of Cochrane Reviews

• Go to the Cochrane Reviews Home page and scroll down to Browse Free Summaries
  
• Click on a topic OR scroll down and click on All Summaries
• The All Summaries page will allow you to
  • Search by entering words and short phrases (as headache, multiple sclerosis drugs, asthma acupuncture
  • Browse by Health Topics (left column)
  • Include only these in the search results
    • Podcasts – audio summaries
    • PEARLS – guidance and advice for real time decisions

Related Blog Items 

• How to read a research paper (and also understand medical/health news items)
• HealthNewsReview.org – Independent Expert Reviews of News Stories (jflahiff.wordpress.com)

Cannot find a plain language summary with the above resources?

Consider asking a reference librarian for help at your local public, academic, or hospital library. Many academic and hospital libraries provide at least limited reference service to the public.
Call or email them for information about their services.

You may also contact me at jmflahiff@msncom.  I will do my best to reply within 48 hours.

Many with Terminal Cancer Still Getting Routine Screens

Advanced cancer patients should not be put through futile testing at end of life, experts say

Excerpts from a Health Day news item

TUESDAY, Oct. 12 (HealthDay News) — Many patients with incurable cancer are still being screened for common cancers, although these tests are unlikely to provide any benefit, researchers from Memorial Sloan-Kettering Cancer Center in New York City have found.

Specifically, many patients diagnosed with advanced lung, colorectal, pancreatic, gastroesophageal or breast cancer are still undergoing the ordeal of routine breast, prostate and colon cancer screening, said the researchers. Not only might these patients suffer from invasive procedures like colonoscopies near the end of life, the researchers said, but they face the unnecessary risk of additional tests, biopsies and psychological distress resulting from the detection of new malignancies.

“For patients living with advanced cancer, cancer screening should not be a routine procedure,” said lead researcher Dr. Camelia S. Sima, an assistant attending biostatistician.

[snip]

The report is published in the Oct. 13 issue of the Journal of the American Medical Association.
The article is freely available at http://jama.ama-assn.org/cgi/content/full/304/14/1584

[snip]

There needs to be greater awareness that cancer screening when one is near the end of life is unlikely to provide a benefit, Sima pointed out.

“Screening guidelines could be reassessed to address the appropriateness of screening for patients whose very limited life expectancy due to advanced cancer negates any potential benefit that may be derived,” Sima said.

Commenting on the study, Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society, said that “we can do a lot of good with screening, but we have to recognize that there comes a time when it’s simply not the right thing to do.”

Lichtenfeld suggested that patients should discuss the appropriateness of a screening test with their doctor. “Putting people at the end of life through screening is not appropriate for the person, and from a societal viewpoint, it’s not a good use of our limited resources,” he said.

“Why would this happen in the first place?” Lichtenfeld asked. “It flies in the face of compassion; it flies in the face of common sense.”

 

 

Meeting End-Of-Life Needs (A Hospice Library)

The Hospice Institute of Hospice of the Western Reserve in Cleveland, Ohio has created a specialized library to meet end-of-life educational needs. According to a news item, the library collection of over 1,500 items is accessible to the public. Librarians offer free personalized library services. An online form is available here.

The library has several Web based offerings

**Book Lists

**Pediatric Care Guide

** Bereavement Support Resources