Medicine and ED docs: should you consult surgery for your demented patient?

As the surgery consult resident, I am frequently called by the emergency department or the medicine teams in the hospital to evaluate patients to see if they will need surgery.  I was recently called about an elderly patient (in his late 80's) with severe advanced dementia and other comorbidities who has no immediate family members.  The medicine physicians wanted to know if the patient would benefit from surgery.

Here is a statement from the Alzheimers Association website:

The research on the efficacy of aggressive treatments and the burden experienced by the person in the advanced stage of Alzheimer’s disease, the Association supports the elimination of hospitalization and aggressive treatments, including cardiopulmonary resuscitation, dialysis and all other invasive technologies, in favor of palliative and comfort care in the person’s residence, whether in the person’s home or in a nursing facility.

To assist individuals and families as they make decisions about end-of-life care, the Association recommends that physicians and other health care providers educate families regarding the choice of burdensome treatments in the advanced stages of dementia versus the choice to provide comfort through palliative and hospice services.

The Association asserts that open and honest communication between health care providers and families as to the person's prognosis as well as the implications for aggressive treatments will assist families in making compassionate choices.

As it turns out, the patient doesn't need surgery.  What if he did?  Should we operate?  Think the fact that I'm writing this right now suggests my own feelings about this particular consult.  The "default setting" in the American medical system is to constantly intervene and "treat" unless we can get someone from the patient's family to tell us not to.  Is it a sign of moral cowardice to fail to stand up to the system, to stand up for the patient? 

Why is it not the default option to restrain ourselves and let the individual's body follow its natural course?

The Economist on Mitt Romney: "nobody knows who this strange man really is."

The liberal media is at it again.  The left-wing Economist newspaper (/sarcasm) has not once, in the last three decades, endorsed an incumbent president for re-election.

2012 is sounding like it could be the first.

"All politicians flip-flop from time to time, but Mr Romney could win an Olympic medal in it."

"Competence is worthless without direction and, frankly, character."

"He has appeared as a fawning PR man, apparently willing to do or say just about anything to get elected."

"Behind all this sits the worrying idea of a man who does not really know his own mind."

"The Romney Programme for Economic Recovery, Growth, and Jobs" is like "Fifty Shades of Grey" without the sex."

"It is a little odd that the number two has a plan and his boss doesn't."

"A business man without a credible plan to fix a problem stops being a credible businessman.  So does a businessman who tells you one thing at breakfast and the opposite at supper."

How to lose the future

Taken as a percentage of GDP, investment in research by the United States is at the lowest level in decades.  Other nations such as Finland and Israel, known for their innovative and entrepreneurial economies, spend far more than the United States.  Cuts in research spending won't hurt us now - they will hurt us in a decade or two.  The time lag between benefit and cost makes such cuts a tempting political target. Enter the Ryan plan, which plans to cut "non-defense" research spending to trim our budget.

We're in a tough time economically, and our deficit is absolutely out of control.  If someone was making the case to me that we just can't afford to increase R&D spending until our fiscal future is secure, I don't think I would find that argument unreasonable, although I wouldn't agree with it. What I do find to be unreasonable is the Republican insistence that the military needs to be spared all forms of spending cuts.  It is the epitome of short sighted to cut general research spending in order to maintain our high current levels of military spending.

Mitt Romney plan will cut research spending, but he has promised to increase military spending (for what threat are our current forces insufficient, I wonder).  Barack Obama has stated he will not spare the military from a greater plan to fix our budgetary crisis, but has nevertheless urged increased spending on research and development.  Americans have been given a choice this election.  They can think about the present, or they can think about the future.  The central theme of pretty much every history book I've read ever, is that great national powers which maintain high levels of military spending to the detriment of other areas of the economy quickly cease to be great powers. 

A very good point re: Ryan medicare plan

Josh Barro on Bloomberg reminds us that the Ryan Plan would delay actual reforms to Medicare for 10 years. 

 

What are the chances that such reform will withstand a decade of partisan demagoguery by opportunist politicians?  Congress has proven time and time again that even when congress passes its own legislation that "forces" spending cuts down the road, the spending cuts don't happen.  Look at the medicare doc fix - every year, congress passes a 1-year funding bill to avoid the cut.  Listen to the howls of politicians about impending mandatory cuts from sequestration.  What are the chances those cuts actually go through?

 

A similarly lame attempt to "reform" medicare a decade down the road will similarly fail.  There is no shortcut to real reform, but that's what we need to curb health care spending in the long term.  Instead of gimmicks, real reform is going to require serious policy analysis, honest proposals, intelligent cost-benefit analysis, and good-faith compromise.

 

http://www.bloomberg.com/news/2012-08-17/mitt-romney-s-double-medicare-contradiction.html

Paul Ryan for VP

My biggest concern about a Mitt Romney presidency is that he would end up being a George W. Bush repeat:  expanding defense spending, cutting taxes, while leaving entitlements untouched if we're lucky or larger if not.  After all, if we are going to have big government, we need to pay for it.  The only thing worse than high taxes and big government is low taxes and big government.  In the former case, Americans living in the present are paying for services they receive; in the latter case, Americans in the present are living large while future generations are stuck paying the bills.

Up till now, Romney really wasn't very clear about where he stood on things.  We know for certain that he is a Keynesian, and has expressed that he would hesitate to cut federal spending if the economy was still weak.  He has promised to increase military spending, and to cut taxes.  Without massive cuts to entitlements, the math doesn't even begin to add up.  Paul Ryan as VP shows how Mitt Romney makes the equation work.  It is a relief that Americans will actually have a real choice to make this November.

If I knew that Ryan's strategy to cut spending would actually work, I might be willing to vote for the challengers.  I remain extremely skeptical that the Ryan plan will actually cut health spending rather than merely transfer it.  The problem isn't medicare per say, the problem is the health care system itself.  It is how we deliver care; it is about the incentives to do more that doctors, hospitals, and patients all have, and the consequences if they do less.  Our system only knows how to do more - there is no restraint.  Changing who pays for medicare doesn't change the system itself; in fact, it is more likely to exacerbate the worst tendencies of the system.  In a previous post, I explain why I don't think the Ryan plan will work.

This is what democracy is all about - real choices.  No matter who wins in November, I hope that administration will have some support from congress to enact their proposed agenda.

Enjoy your right to drive a car, part 3

Three hundred thousand miles...zero accidents.

Part 1:  why I think it will eventually be illegal for humans to pilot automobiles on public roads, and why we should embrace that future. 

Part 2:  intersections of the future.

I used to think the transition to computer-only driving was at least two decades out.  Now I'm not so sure - it could come much sooner because the technology is moving really quickly.  There are huge economic and safety gains to be had from banning error-prone humans from getting behind the wheel of cars.  Once those gains become apparent, there might be a massive push towards computer-only driven cars.
Considering how dependent on cars many Americans are for transit, the future could be pretty scary from a privacy standpoint.  If a citizen needs to tell the car's computer where to take them, then someone could potentially be tracking where that individual is going at all times.  Other than the government, there are of course other interested parties (spouses?  parents?) that might be keen to check on the car's recent travel history...

HCA "controversy" is the butt of a four+ year old internet parody video

There is a video on youtube which is now over four years old which many physicians-in-training find hilarious:

 

http://youtu.be/xskFo75Wdhs

 

The "news" that physicians in Florida are performing unindicated procedures because they have a financial incentive to do so is not news to anyone in the health care profession.

 

People respond to incentives.  There are incentives to perform procedures.  Physicians are people.  Follow me?