July 4, 2018

BAH, IMMIGRANTS....:

THIS SURGEON IS INJECTING HUMANITY INTO U.S. HEALTH CARE (Anjana Ahuja, 7/02/18, OZY)

This episode may have seeded the announcement that Gawande is to be chief executive of a nonprofit venture funded jointly by Amazon, Berkshire Hathaway and JPMorgan Chase & Co., formed to address the health of their combined million-plus workforce.

"I have devoted my public health career to building scalable solutions for better health care delivery," Gawande says. "Now I have the backing of these remarkable organizations to pursue this mission with even greater impact.... This work will take time but must be done. The system is broken, and better is possible."

Other than boosting employee health and cutting costs, the prescription for the as-yet-unnamed Boston venture is unclear. But the bloated $3 trillion U.S. health care industry is seen as ripe for the scalpel. Gawande -- who has written four best-selling books on medicine, founded projects to improve health in developing countries and received a MacArthur Foundation "genius" award -- will now have a generously funded test bed to think differently. The involvement of Amazon suggests technological disruption; bricks-and-mortar hospitals seem, literally, an outmoded operating system in a digitized world.

It is an unexpected direction for the doctor who was tipped to be surgeon general in a Hillary Clinton administration. "I don't think it's excessive to call him our most distinguished living doctor," says Andrew Franklin, a friend and the founder of Profile Books, which publishes Gawande's works in the U.K.

"He has a real sense of the power of medicine to improve the world. And he's become fantastically successful without becoming obnoxious. I don't have many heroes, but Atul is one of them," Franklin says.

Gawande was born in 1965 in New York City -- the family later moved to rural Ohio -- to immigrant Indian doctors: His father, Atmaram, was a noted urologist, his mother, Sushila, a pediatrician. The couple supported philanthropic causes in the U.S. and India...



Letting Go: What should medicine do when it can't save your life? (Atul Gawande, 8/02/10, The New Yorker)

This is the moment in Sara's story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic cancer--or, for that matter, a similarly advanced case of emphysema or congestive heart failure--what would you want your doctors to do?

The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country's long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.

Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end--to an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.

The subject seems to reach national awareness mainly as a question of who should "win" when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can't afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they're debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made.

Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone I'd known since college. "I'm running a warehouse for the dying," she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didn't want to die that way. But her children couldn't let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness.

Almost all these patients had known, for some time, that they had a terminal condition. Yet they--along with their families and doctors--were unprepared for the final stage. "We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point," my friend said. "The problem is that's way too late." In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one's final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or "It's O.K." or "I'm sorry" or "I love you."

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system's expense. It is how we can build a health-care system that will actually help dying patients achieve what's most important to them at the end of their lives.



Posted by at July 4, 2018 5:55 AM

  

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