How much is enough - Stichting Humanitas

How much is enough?Nursing ManagementChicagoNov 1994------------------------------------------------------------------------------ Authors: Curtin, Leah LVolume: 25Issue: 11Start Page: 30ISSN: 07446314Subject Terms: ReimbursementOlder peopleMedicareHealth careEthicsClassification Codes: 9190: United States8320: Health care industry2410: Social responsibility1200: Social PolicyGeographic Names: USAbstract:A case study of Sam Arbuncle, a 108-year-old patient admitted to the hospital emergency room after suffering from a syncopal episode (loss of consciousness with urinary incontinence), is presented. He is functionally and mentallyvery active and says that his most pressing problems are that he cannot hear well and he has trouble chewing because he lost his lower dentures. After a thorough workup, he went to surgery for an aortic valvuloplasty to improve his recurrent syncopal symptoms. Arbuncle's case raises many interesting issues. One involves the vagaries of Medicare reimbursement. Frequently, the resultis that sophisticated procedures are executed, but they do not necessarily enhance life. A 2nd set of issues involves symptom management. Arbuncle was just as concerned about his hearing loss and his dentures as he was about his bout of syncope, but those things are not covered by Medicare. The 3rd set of issues concerns rationing access to healthcare services and the transferenceof wealth to the elderly.Copyright S-N Publications, Incorporated Nov 1994Full Text:Sam Arbuncle* is a 108-year-old male admitted to the hospital through the emergency room. He suffered a syncopal episode (loss of consciousness with urinary incontinence)--his third in the last 3 months. He is insured by Medicare, Parts A and B, supplemented by Blue Cross and Blue Shield. His medical history reveals chronic lymphocytic leukemia; cerebrovascular insufficiency; mitral insufficiency; mild renal insufficiency; S/P carcinomaof the prostate; mild macrocytic, normochromic anemia; a squamous cellcarcinoma of the right parietal area; and, recently, Hemoccult-positive stools. He used to smoke seven or eight cigarettes a day, but he quit smoking morethan 50 years ago. Occasionally he will have an alcoholic drink with friends. Mr. Arbuncle has no children, and his wife died 3 years ago--a loss of companionship and intimacy that he misses deeply. However, despite hispersonal losses, advanced age, and lengthy list of medical problems, he is functionally and mentally very active. He takes only two medicationsregularly: 30 mg of Restoril every night for sleep and Reclizine every morning for dizziness. Mr. Arbuncle lives at a senior residence hotel, works as amaitre d' at a local restaurant three times a week, and plays bingo regularly. He says that his most pressing health problems are that he can't hear well and he has trouble chewing because he lost his lower dentures.Although he uses a cane (he has been somewhat unsteady on his feet the lastfew years), he does his own shopping, with the help of several friends, and manages his own finances.During his admission interview, he asked a resident physician how manyRestoril tablets it would take to "let him sleep forever." Concerned as muchfor his mental state as his physical, the resident asked him if he wanted to die. Sam said, "No," but he admitted that he was "feeling blue" because he missed his wife. The geriatric consultation team reached the conclusion thatthe sadness he was experiencing was normal considering the losses he had suffered. Mr. Arbuncle said he was very sorry that he had distressed thedoctor. However, he requested--and was given--a "no code" order.After a thorough workup, he went to surgery on a Thursday, for an aortic valvuloplasty to improve his recurrent syncopal symptoms. He went home the following Monday--a 4-day stay! He spent only 1 day in the ICU, received two units of packed cells for his anemia, walked in the hall the second day postop, and was discharged without incident.A multitude of issues...Mr. Arbuncle clearly is a remarkable man. So much of the medical-ethicsliterature focuses on overtreatment, particularly of the very elderly or the hopelessly ill, that I expected this case study to address that problem. Itdoes not, although it does raise many interesting issues:* One set of issues involves the vagaries of Medicare reimbursement.Frequently, the result is that sophisticated procedures are executed, but they do not necessarily enhance life. Often these procedures are performed at great mental and physical cost to the elderly and their families--and greatfinancial cost to society. According to recent studies, 17% of coronary angiographies, 33% of carotid endarterectomies, 17% of upper G.I. endoscopies, and 44% of coronary bypasses performed on the elderly were eitherinappropriate or questionable.(1)On the other hand, many believe that prejudice or perhaps merely ignoranceleads to medical neglect of the aged. Certainly there are many who claim that "doctors deliver shoddy care to the elderly," veering from under-to overtreatment.Although many might think that performing an open-chest procedure on a 108-year-old man was "excessive," they would be unlikely to sustain that opinionwhen they learned that this intervention returned Mr. Arbuncle to an active life. Certainly his rapid recovery and return home demonstrated that he "was up to the procedure."* A second set of issues involves symptom management. The irony is that Sam Arbuncle was at least as concerned about his lost dentures, which he could not get replaced, and his hearing loss, which could be corrected by a hearing aid, as he was about his bout of syncope. In fact, he was more concerned about them because they affected his life more, and more regularly than the syncope. He wasn't afraid of dying so much as he was afraid of living a diminished life. That's why he asked how many Restoril tablets he'd have to take to sleep forever.That which was most distressing to him--and to many of the elderly--isprecisely what is not covered by Medicare.* The third set of issues raised by this case study surrounds the whole question of rationing access to healthcare services--and, in fact, the whole issue of the transference of wealth to the elderly. The latter being an inescapable consequence of taxing the young to pay for care and services to a rapidly growing older generation.The Atlantic Monthly reports that only 12% of the elderly were classified as poor, but 21% of children under the age of 18 were poor. "Other indicators such as noncash income, financial assets, and home ownership rates also show that the typical elderly household is now considerably better off than the typical young family...[Yet] today more than 60% of all federal benefit spending flows to the 12% of Americans who are age 65 or older..." Moreover, the authors go on to note, "During the 1980s the 76 million members of the Baby Boom generation moved into their prime productive years....The result was an automatic surge in federal revenue--especially because the women of this generation have been far more likely than their mothers to work for wages, and therefore to contribute to taxes....The growth rate of the retirement-age population has actually been slowing down since the mid-1980s, owing to the declining birth rates of the late 1920s. Yet the United States is stillrunning enormous budget deficits [entitlements account for more than 45% ofall federal spending--or 12% of the GNP--today]." What will happen when the Baby Boomers start retiring? "If one adopts the economic, demographic, and medical assumptions used by the Social Security Administration and the Health Care Financing Administration, the total cost will rise...to 21% of GNP [best case] or to 31% of GNP [most plausiblecase]."(2)In 1954, Joseph Fletcher wrote a book entitled Medicine and Morals. In it, he proposed that freedom of choice was the highest moral value, and that the struggle against nature was medicine's prime mission. His work captured the public's imagination and, to some extent, gave rise to the fledgling field of bioethics. Daniel Callahan, writing in The Hastings Center Report, says, "The field of bioethics has displayed two serious deficiencies, exactly the kind that usually afflict golden children: It has failed to pursue with sufficient imagination the idea of the common good, or the public interest, on the one hand, and that of personal responsibility, or the moral uses of individual choice, on the other."(3)The problems posed by an aging nation will challenge our traditions and our ethics as they alter the ratio between old and young in our society. A nation that claims that it cannot afford 65c to immunize a 10-year-old and yet spent$19 billion subsidizing the health care of Medicare recipients with incomes of more than $50,000 a year has much to change. Beyond question, among the proposed changes will be the rationing of access to health care. Much could be done today to reduce unhelpful and inappropriate medical intervention in the lives of the elderly if reimbursement priorities shifted. Even in the absence of such a shift, geriatric consultation teams in all facilities could follow up on all patients admitted who are over 65 to help ensure that their care is appropriate, to see to it that patients' decisions are respected, to help educate families to their rights, and to help ensure that what can be done is done to help improve the quality of living. Perhaps if we do, this nation will not engage in across-the-board rationing by age. Otherwise, remarkable men and women like Sam Arbuncle may not have a chance to end their days gracefully. References1. "How Medicine Mistreats the Elderly." U.S. New & World Report, Jan. 18, 1993, pp. 72-9.2. Howe, Neil, and Phillip Longman, "The Next New Deal," The Atlantic Monthly, April 1992, pp. 88-99.3. Callahan, Daniel, "Bioethics: Private Choice and Common Good," The Hastings Center Report, May-June 1994, 24:3:28.Reproduced with permission of the copyright owner.Further reproduction or distribution is prohibited without permission.。