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MEDICAL JOURNAL STUDIES
HIGHLIGHT DANGER OF "ADVANCE CARE PLANNING" AND
"COMPARATIVE EFFECTIVENESS" HEALTH BILL
PROVISIONS
Part Two of Three
Editor's note. The following
appeared last Friday on the invaluable blog
http://powellcenterformedicalethics.blogspot.com.
Two New England Journal of
Medicine (NEJM) studies published on Thursday
show how medical conclusions based on the
perceived quality of life of certain groups or
of older people can pose risks in the areas of
Advance Care Planning and "comparative
effectiveness" research. Central to the Health
Care Restructuring bills is the concept that
cost cutting measures will be sufficient to make
up for financing shortfalls. One of these
measures is the promotion of advance directives.
There have been several recent studies showing
how advance directives and end of life
conversations generally yield cost savings. (For
more see
http://powellcenterformedicalethics.blogspot.com/2009/08/advanced-care-planning-provisions-must.html)
The NEJM studies focus on two
conditions in particular: Kidney Dialysis and
Dementia. One of the
studies, entitled "The Clinical Course of
Advanced Dementia," concluded that, "Distressing
symptoms and burdensome interventions are also
common among such patients [patients with high
6-month mortality rates]. Patients with health
care proxies who have an understanding of the
prognosis and clinical course are likely to
receive less aggressive care near the end of
life."
 The
study states that in the last three months of
life 49.7% of those in the study underwent at
least one "burdensome intervention." Those
included hospitalization, visits to the ER,
parenteral therapy or tube feeding. The patients
were mainly treated for pneumonia, fever, and
eating problems, complications frequently
experienced by patients with advanced dementia.
As the NEJM study found, these
"burdensome interventions" were less likely to
be given to those who had a surrogate
decision-maker. In those cases, the study fails
to highlight that the patients were not dying
from the underlying dementia, but from
starvation that a feeding tube could have
avoided or an infection that 'parenteral
therapy' (also known as an injection or infusion
– probably of an antibiotic) could have treated.
Moreover, the phrase "burdensome
interventions" is a conclusion based on a very
subjective determination. It employs a value
judgment that a person with dementia lacks value
or an adequate quality of life. An antibiotic
for a fever or a feeding tube would certainly
not be considered " burdensome"--for
example--for a young mother with an injury.
The study suggests that instead
of life-preserving interventions more attention
should be given to treating distressing symptoms
such as dyspnea (a breathing problem
characterized by unpleasant or uncomfortable
respiratory sensations), pain, pressure ulcers,
aspiration, and agitation. The study implies
that more emphasis ought to be on keeping those
near death comfortable--an admirable goal--but
not one that ought to be coupled with neglect of
treatable conditions like fevers and
dehydration. This sort
of study, and others like it that are becoming
more prevalent, will pave the way for two
different dangerous roads. The first is in the
area of advance planning.
The study shows that patients
with proxy decision-makers tend to die from
non-treatment (and save money). When a person
being counseled to make advance decisions about
accepting or rejecting treatments (for oneself
or for a person for whom he or she holds a
health care power of attorney) is encouraged to
think of these sort of life-preserving
treatments as "burdensome" for those with
dementia, then the counseled individual will no
doubt be more likely to authorize denial of
treatment that will cause death–-perhaps
unknowingly--from fairly commonplace
non-treatment. The other
dangerous road is that of comparative
effectiveness research. Without proper
protections, studies such as this one could be
cited as comparative effectiveness research and
be used to make coverage decisions in ways that
treat the life of a person with dementia as
having less value This could result in outright
denial of medical coverage for many treatments
that are simple and necessary to preserve the
lives of patients with dementia.
The other NEJM study, entitled,
"Functional Status of Elderly Adults before and
After Initiation of Dialysis," looked at nursing
home patients who received dialysis. It did not
include a comparison group of patients who did
not receive dialysis, so a true comparison rate
of extra life gained by dialysis is unknown. The
study shows that despite dialysis, there was
"substantial and sustained decline in functional
status." The danger is
that such studies may be used to deny coverage
(or encourage patients subjected to "advance
care planning" to reject) dialysis because it
does not "restore health or functional status"
despite the fact that it likely prevents a
hastened death.
Please send your comment on
this or any other of the three parts of today's
TN&V to
daveandrusko@gmail.com.
Part Three
Part One |
