Health Care Technology and End of Life Issues

[Aardvark86]

So over the weekend, I was having a really interesting discussion with a friend about health care technology in the end of life context, and particularly about what, and when, insurance should cover it. A penny for your thoughts and reactions, or at least for the ones that are non-trolling in nature.

When I think back over my lifetime, when I was young, everybody died of heart disease. Then, everybody died of cancer. Now, everybody dies of dementia-related conditions. So long term, technologies do seem to "work". But as I thought about it, when the technology is initially introduced, it may improve incremental survivability, but little if any improvement in quality of life during that incremental survivability period. Thankfully, QoL actually seems to catch up after a while, even if not "all the way".

Should insurance pay for the initial survivability without QoL, or before QoL catches up? How long? Recognize, of course, that without it, the technology probably gets abandoned.

 

[Rifler]

"Insurance" should be tailorable to what you want to pay for,... Extensive end of life care is expensive and frequently a waste of money, but if that's what you want, and are willing to pay for, so be it,... Most people would be better served with less coverage and a lower premium.

 

[RockyMtNole]

Who’s to determine what’s quality of life?

 

[LunchBox50]

I had a similar conversation recently about a relative who has Stage 4 lung cancer and a massive infection that's going to ultimately be the fatal blow. Mayo, UIHC, UNMC, and others all declined to perform a risky procedure that would have removed the infection, but there are some who want to keep pumping in antibiotics and other meds in hopes of (briefly) holding off the inevitable death of someone who is in really bad shape, bedridden, and not going to get any sort of quality time from it. I can definitely see the argument that insurance shouldn't be paying for that.

 

[Rifler]

Who’s to determine what’s quality of life?

Your check book...

 

[Aardvark86]

"Insurance" should be tailorable to what you want to pay for,... Extensive end of life care is expensive and frequently a waste of money, but if that's what you want, and are willing to pay for, so be it,... Most people would be better served with less coverage and a lower premium.

Indeed, for all of the histrionics about Canada's NHS, a system where public insurance programs were minimalist but there was a robust supplemental coverage market for various menus of services might be an interesting animal.

 

[Urohawk]

I had a similar conversation recently about a relative who has Stage 4 lung cancer and a massive infection that's going to ultimately be the fatal blow. Mayo, UIHC, UNMC, and others all declined to perform a risky procedure that would have removed the infection, but there are some who want to keep pumping in antibiotics and other meds in hopes of (briefly) holding off the inevitable death of someone who is in really bad shape, bedridden, and not going to get any sort of quality time from it. I can definitely see the argument that insurance shouldn't be paying for that.

Every year I designate a trainee at my hospital to come into my room and put the pillow over my face for these exact reasons.

 

[Jonathan Assbutt Jr.]

The should would seem to be what people are willing to pay for.

But what's a hypothetical here? Would seem to be something along the lines of a really promising drug to slowdown dementia, efficacious in ways other treatments haven't been to this point for the disease. Bit of a breakthrough, but only first stab. Nothing much towards a cure, slows down the inevitable a bit. Not a huge quality of life gain. Yeah, most people are going to expect that to be covered.

 

[Aardvark86]

Every year I designate a trainee at my hospital to come into my room and put the pillow over my face. for these exact reasons.

This guy?

 

[GesterHawk]

Every year I designate a trainee at my hospital to come into my room and put the pillow over my face. for these exact reasons.

Kinky

 

[LunchBox50]

Every year I designate a trainee at my hospital to come into my room and put the pillow over my face. for these exact reasons.

It always seems like whenever you have more than two siblings involved, one of them wants every last exhaustive measure taken, regardless of the outcome or condition. And the sibling that wants all of the death-delaying work to occur is usually the one who lives in another time zone.

 

[Urohawk]

The debate I always pose: At one point there were 5, end stage prostate cancer treatments that each gave about 3 months of additional life but each cost 100K. They are not equal years as it's cancer so the longer they go, the more deterioration there is over the last few months of life.

I always challenge the medical students by asking what would the average person choose: A. Spending 500K to keep someone alive for an additional year and a half vs B. giving someone 100-200K worth of treatment, and then telling them you will cover the funeral expenses and give 50K to their estate Would save an estimated 250K in insurance savings.

 

[Urohawk]

It always seems like whenever you have more than two siblings involved, one of them wants every last exhaustive measure taken, regardless of the outcome or condition. And the sibling that wants all of the death-delaying work to occur is usually the one who lives in another time zone.

This is 100% correct. Or my other favorite is keep them alive for another week and then we can withdraw care. I think I can get there in 3-4 days at 200K+ for ICU care.

 

[LunchBox50]

The debate I always pose: At one point there were 5, end stage prostate cancer treatments that each gave about 3 months of additional life but each cost 100K. They are not equal years as it's cancer so the longer they go, the more deterioration there is over the last few months of life.

I always challenge the medical students by asking what would the average person choose: A. Spending 500K to keep someone alive for an additional year and a half vs B. giving someone 100-200K worth of treatment, and then telling them you will cover the funeral expenses and give 50K to their estate Would save an estimated 250K in insurance savings.

That's a great way of putting it.

 

[Rifler]

Indeed, for all of the histrionics about Canada's NHS, a system where public insurance programs were minimalist but there was a robust supplemental coverage market for various menus of services might be an interesting animal.

This would be my preferred approach for a new health care system,.... Basic coverage for all, at a cost that society can afford to pay for,.. Supplemental plans for those who want and can afford them.

 

[GesterHawk]

It always seems like whenever you have more than two siblings involved, one of them wants every last exhaustive measure taken, regardless of the outcome or condition. And the sibling that wants all of the death-delaying work to occur is usually the one who lives in another time zone.

All my siblings have designated my oldest sister as our non-spouse medical decision maker as she is the most pragmatic of us and would not allow us to be tube-fed vegetables.

 

[52317Hawk]

So over the weekend, I was having a really interesting discussion with a friend about health care technology in the end of life context, and particularly about what, and when, insurance should cover it. A penny for your thoughts and reactions, or at least for the ones that are non-trolling in nature.

When I think back over my lifetime, when I was young, everybody died of heart disease. Then, everybody died of cancer. Now, everybody dies of dementia-related conditions. So long term, technologies do seem to "work". But as I thought about it, when the technology is initially introduced, it may improve incremental survivability, but little if any improvement in quality of life during that incremental survivability period. Thankfully, QoL actually seems to catch up after a while, even if not "all the way".

Should insurance pay for the initial survivability without QoL, or before QoL catches up? How long? Recognize, of course, that without it, the technology probably gets abandoned.

I'm confused. By technologies do you mean treatments? Do you have an example of technology?

 

[fatpiggy]

I thought this thread was going to be about euthanasia. Had a distant relative take this option in Colorado a couple weeks ago. Is euthansia covered by insurance?

 

[GesterHawk]

The debate I always pose: At one point there were 5, end stage prostate cancer treatments that each gave about 3 months of additional life but each cost 100K. They are not equal years as it's cancer so the longer they go, the more deterioration there is over the last few months of life.

I always challenge the medical students by asking what would the average person choose: A. Spending 500K to keep someone alive for an additional year and a half vs B. giving someone 100-200K worth of treatment, and then telling them you will cover the funeral expenses and give 50K to their estate Would save an estimated 250K in insurance savings.

I feel that, as a whole, we focus more on keeping folks alive than we do on letting them decide their own end.

I would much rather take a $200k payout at the end to do with what I want while taking minimal steps to prolong life. Let me use that money to take that last trip, or help one of my kids buy a house or put my grandkids through college.
Then give me a giant bottle of fentanyl and let me slide off some where and some when I choose.

 

[GesterHawk]

I thought this thread was going to be about euthanasia. Had a distant relative take this option in Colorado a couple weeks ago. Is euthansia covered by insurance?

I doubt it as it still really isn't very legal.

 

[LunchBox50]

I thought this thread was going to be about euthanasia. Had a distant relative take this option in Colorado a couple weeks ago. Is euthansia covered by insurance?

Not to my knowledge, but I wish we as a society were more honest/open about things like this and making it available.

 

[Aardvark86]

I'm confused. By technologies do you mean treatments? Do you have an example of technology?

it could be a drug, it could be a device (and any associated administration procedure).

I'd actually be less concerned with something that is,, say, a new surgical technique, as it's essentially just a labor cost differential which could probably be addressed through relatively easy actuarial adjustments.

 

[baltimorened]

The debate I always pose: At one point there were 5, end stage prostate cancer treatments that each gave about 3 months of additional life but each cost 100K. They are not equal years as it's cancer so the longer they go, the more deterioration there is over the last few months of life.

I always challenge the medical students by asking what would the average person choose: A. Spending 500K to keep someone alive for an additional year and a half vs B. giving someone 100-200K worth of treatment, and then telling them you will cover the funeral expenses and give 50K to their estate Would save an estimated 250K in insurance savings.

bet you'd get a different answer if you asked the person with the illness...I remember Zeke Emanuel, during the Obamacare debate, saying all government health insurance should end when the patient reaches 75. Of course he was much younger than 75 at the time.

 

[Urohawk]

bet you'd get a different answer if you asked the person with the illness...I remember Zeke Emanuel, during the Obamacare debate, saying all government health insurance should end when the patient reaches 75. Of course he was much younger than 75 at the time.

Completely disagree. You know who defers the most care and dies earlier, physicians. We've seen the hell people get put through. Most don't choose it.

Study: Physicians Choose Less Intensive End-of-Life Care than General Public

Physicians are less likely than the general public to die in the hospital.

news.weill.cornell.edu

 

[fatpiggy]

I doubt it as it still really isn't very legal.

I also had questions about the legality of it so I just looked it up.

I previously used the wrong terminology, apparently in Colorado it is not euthanasia. It is called “medically assisted dying.”


To someone else’s point above, if you were diagnosed as terminal, I don’t think it’s unreasonable to be offered some payout to take medically assisted dying rather than run up medical bills fighting to the end.

People could take that money and do one last blowout trip, they could give it to their children or whatever they want.

Interesting topic

 

[GesterHawk]

I also had questions about the legality of it so I just looked it up.

I previously used the wrong terminology, apparently in Colorado it is not euthanasia. It is called “medically assisted dying.”

I am not sure who foots the cost on that, but the XL bottle of morphine that they use to do it probably doesn't move the needle cost wise.

 

[fatpiggy]

I am not sure who foots the cost on that, but the XL bottle of morphine that they use to do it probably doesn't move the needle cost wise.

Understood.

I suppose I was thinking of a situation say like pancreatic. My business partners father-in-law has diabetes and went in for a routine blood draw a week ago. He felt fine absolutely nothing wrong. He got a call saying that something was off with his blood bloodwork and needed to come back in for more testing. He was diagnosed with pancreatic cancer..

So I suppose I am saying if someone offered him say $500,000, he could live for as long as he could stand the pain and then when he couldn’t stand it any longer, he could just check out instead of running up millions of dollars in medical bills.

In the meantime, he has 500 grand to either go on a trip do something crazy or he can choose to leave it to his children whatever he wants.

Just a thought. He gets 500 grand and the taxpayer save a couple million bucks.

 

[GesterHawk]

Understood.

I suppose I was thinking of a situation say like pancreatic. My business partners father-in-law has diabetes and went in for a routine blood draw a week ago. He felt fine absolutely nothing wrong. He got a call saying that something was off with his blood bloodwork and needed to come back in for. He was diagnosed with pancreatic cancer..

So I suppose I am saying if someone offered him say $500,000, he could live for as long as he could stand in the pain and then when he couldn’t stand it any longer, he could just check out instead of running up millions of dollars in medical bills.

In the meantime, he has 500 grand to either go on a trip do something crazy or he can choose to leave it to his children whatever he wants.

Just a thought. He gets 500 grand in the taxpayer save a couple million bucks.

Yeah, that is basically my post in #19. I would rather take a shorter life with more benefits to me and my family than a longer life that is miserable and that leaves the worst of all images in my kids' mind of me for the rest of their lives.

As fathers we spend so much of our time with our children trying to be super men of one fashion or another. I don't want to be the shrunken, sick version of me to be the last thing they remember of me at the end. I don't think many of us do.
There is strength in fighting and there is strength in knowing when not to fight. Both are equally powerful messages to teach your children.

 

[The_Joker13_rivals]

Who’s to determine what’s quality of life?

Republicans?

 

[Urohawk]

To someone else’s point above, if you were diagnosed as terminal, I don’t think it’s unreasonable to be offered some payout to take medically assisted dying rather than run up medical bills fighting to the end.

I was more implying we should do the right thing as society and have hard core discussions about death. Either we shouldn't entertain paying for it or have some sort of cap. Hell, we can't even say what a person died from in their obituary- suicide, cancer, drug overdose, etc. "He died of a long-term illness"

I don't think it's practical to transfer wealth over some end of life payout. Much of my point is when you're own money is not on the line, you're more than happy to spend it all until the end. Now imagine you had to foot 10% of the bill on your end of life care (or your estate). People would be less quick to jump on "doing everything."

 

[SB_SB]

The debate I always pose: At one point there were 5, end stage prostate cancer treatments that each gave about 3 months of additional life but each cost 100K. They are not equal years as it's cancer so the longer they go, the more deterioration there is over the last few months of life.

I always challenge the medical students by asking what would the average person choose: A. Spending 500K to keep someone alive for an additional year and a half vs B. giving someone 100-200K worth of treatment, and then telling them you will cover the funeral expenses and give 50K to their estate Would save an estimated 250K in insurance savings.

Urohawk, I generally agree with your posts and have respect for what your post. Buuuuuut, I don't think that's a valid challenge. For one thing, to keep someone alive for 1.5 years might be huge deal to that family. My BIL lived 1.5 years after being diagnosed (with stomach cancer) and that time meant a lot. He got to see his youngest child graduate high school. He wanted the time, 50K to his estate meant nothing and in fact is an insult to value his life at 50K. He continued to work for most of the 1.5 years and so he made a lot more money for his family than 50K. The 50K would only come into play for a poor family. And I think it's terrible to give that option to a poor family. It's like poor people selling body parts to get money. It's not ethical, in my opinion.

 

[fatpiggy]

I was more implying we should do the right thing as society and have hard core discussions about death. Either we shouldn't entertain paying for it or have some sort of cap. Hell, we can't even say what a person died from in their obituary- suicide, cancer, drug overdose, etc. "He died of a long-term illness"

I don't think it's practical to transfer wealth over some end of life payout. Much of my point is when you're own money is not on the line, you're more than happy to spend it all until the end. Now imagine you had to foot 10% of the bill on your end of life care (or your estate). People would be less quick to jump on "doing everything."

I was more implying we should do the right thing as society and have hard core discussions about death. Either we shouldn't entertain paying for it or have some sort of cap. Hell, we can't even say what a person died from in their obituary- suicide, cancer, drug overdose, etc. "He died of a long-term illness"

I don't think it's practical to transfer wealth over some end of life payout. Much of my point is when you're own money is not on the line, you're more than happy to spend it all until the end. Now imagine you had to foot 10% of the bill on your end of life care (or your estate). People would be less quick to jump on "doing everything."

I think the example discussed in my post does shift some responsibility onto the patient though.

People would be less quick to “doing everything” if you knew you could 1) lessen your pain and suffering while 2) leaving a nice payment to your children and 3) saving the taxpayer money. I think that sounds like a lot of wins.

Not sure it’s ethical though. What if you accepted a payment, spent the money, and then changed your mind. The right thing to do would be to deny that person care. Would be tough.

 

[Urohawk]

Urohawk, I generally agree with your posts and have respect for what your post. Buuuuuut, I don't think that's a valid challenge. For one thing, to keep someone alive for 1.5 years might be huge deal to that family. My BIL lived 1.5 years after being diagnosed (with stomach cancer) and that time meant a lot. He got to see his youngest child graduate high school. He wanted the time, 50K to his estate meant nothing and in fact is an insult to value his life at 50K. He continued to work for most of the 1.5 years and so he made a lot more money for his family than 50K. The 50K would only come into play for a poor family. And I think it's terrible to give that option to a poor family. It's like poor people selling body parts to get money. It's not ethical, in my opinion.

First, I'm sorry you lost your brother in law. If he was watching his kid graduate, I imagine he was relatively young. Most would agree, those dying early is perhaps, a different conversation. Those types of cases, are viewed differently by society.

Certainly, no offense is intended and I should have clarified my point. I'm really referring to the elderly, severely infirm, no hope of survival type cases, demented people getting cancer care, etc. No human life is worth 50K. Our insurance system is so broken that once you hit your deductible you can spend whatever you want. I'm just saying 50K (or some number) would incentivize those who are quick at spending other people's money. It's more a thought exercise. I agree, it's incredibly biased. Students have called me out because it allows the rich to get longer end of life care which has all the ethical implications as you alluded to. The counter to it, is how much money are we wasting by bankrupting a system so a 76 year old can live 3 months longer while our young and poor have underfunded insurance.

 

[Urohawk]

I should also comment that we pay top dollars for drugs with minimal results. These 100K cancer treatments with 3 month to live is BS. Now when people see the 100K for Hep C antiviral therapy, they say the drug companies are profiteering on what could be a fatal illness. I say no way. They hit a grand slam. Those Hep C drugs cost 100K but they have a 95% cure rate. A liver transplant from hep C costs about 1.2 to 1.5 million. We should totally pay for it. The drug companies hit a home run and need to be paid for the R+D. Cancer treatments that add 8 weeks to the end of your life. Go back to the drawing board. We will give you 10K for it.

 

[fatpiggy]

I should also comment that we pay top dollars for drugs with minimal results. These 100K cancer treatments with 3 month to live is BS. Now when people see the 100K for Hep C antiviral therapy, they say the drug companies are profiteering on what could be a fatal illness. I say no way. They hit a grand slam. Those Hep C drugs cost 100K but they have a 95% cure rate. A liver transplant from hep C costs about 1.2 to 1.5 million. We should totally pay for it. The drug companies hit a home run and need to be paid for the R+D. Cancer treatments that add 8 weeks to the end of your life. Go back to the drawing board. We will give you 10K for it.

Using your baseball analogy, isn't drug development like hitting a bunch of singles? But you can't hit a grand slam without hitting the singles first. Not sure i agree with your sentiment here.

 

[SB_SB]

First, I'm sorry you lost your brother in law. If he was watching his kid graduate, I imagine he was relatively young. Most would agree, those dying early is perhaps, a different conversation. Those types of cases, are viewed differently by society.

Certainly, no offense is intended and I should have clarified my point. I'm really referring to the elderly, severely infirm, no hope of survival type cases, demented people getting cancer care, etc. No human life is worth 50K. Our insurance system is so broken that once you hit your deductible you can spend whatever you want. I'm just saying 50K (or some number) would incentivize those who are quick at spending other people's money. It's more a thought exercise. I agree, it's incredibly biased. Students have called me out because it allows the rich to get longer end of life care which has all the ethical implications as you alluded to. The counter to it, is how much money are we wasting by bankrupting a system so a 76 year old can live 3 months longer while our young and poor have underfunded insurance.

Thank you for the comments on my BIL, he was 48. And here's something that was interesting at the time (back in 2004). He happened to be friends with the surgeon and after surgery the surgeon actually said, if he wasn't my friend I probably would have just closed him up and given him 6-12 weeks to live. But because he was a friend, the dr spent the time to reconstruct his stomach as best he could, in order to give him the 1.5 years. That has always stuck with me. My mother was a RN and when I was young, I had heard her say more than once, they opened so-and-so up and they were full of cancer so they just closed them. Since my BIL, I now question whether every Dr is doing everything they can for the patient.

I certainly have no answers because it's too difficult to make a decision. Just saying someone is 76 (any number) doesn't tell the whole story. Some people are active at 76 and some people are basically bedridden at 65. I've been through 2 other immediate-family cancers within the last 1.5 years and it has been an eye opener about how someone 29 gets treated and how someone 61 gets treated. I hate to think of the insurance companies making decisions based on age because I don't like how some doctors feel about certain age groups.

 

[m.knox]

So over the weekend, I was having a really interesting discussion with a friend about health care technology in the end of life context, and particularly about what, and when, insurance should cover it. A penny for your thoughts and reactions, or at least for the ones that are non-trolling in nature.

When I think back over my lifetime, when I was young, everybody died of heart disease. Then, everybody died of cancer. Now, everybody dies of dementia-related conditions. So long term, technologies do seem to "work". But as I thought about it, when the technology is initially introduced, it may improve incremental survivability, but little if any improvement in quality of life during that incremental survivability period. Thankfully, QoL actually seems to catch up after a while, even if not "all the way".

Should insurance pay for the initial survivability without QoL, or before QoL catches up? How long? Recognize, of course, that without it, the technology probably gets abandoned.

Now this is a great discussion topic.

I read it once and accept it as true given the fact that both parents have left me, but end of life is really expensive and just as ugly. Once read an article about a Dane who was in for it, and their healthcare system let him have a smoke and some wine every night until his last. Actually sounds practical and empathetic at the same time.

At some point, we need to let go. Heart breaking for sure.