doc
Spring 2016 • Kentucky
incapacitated, the family’s opinions become
a lot more important. Of course, a patient
may have made his decision about when to
initiate end-of-life care and what kind should
be given in this event. He may have also
assigned power-of-attorney to a relative or
trusted friend.
Once end-of-life care is initiated, the
patient, the medical professionals, and the
family should decide on what will constitute
good quality of life for the patient. Since it
is the end of the patient’s life, her desires
should be given priority. It is up to the
healthcare providers and the family to help
facilitate this expected quality of life for the
patient.
Most people would want to be able to
do what they wanted to do, see who they
wanted to see, and remain lucid and as
pain-free as possible at the end of their lives.
These are all laudable goals that can serve as
optimizations or ideals.
Medical professionals must balance the
patient’s desires with what is realistic from
a healthcare standpoint for them to actually
do. Since at this point all are hopefully in
agreement that the patient is dying, somewhat different rules can be applied. If the
patient wants to try riding a horse, let him.
If a patient decides that he wants to banter
with his brother without falling asleep, help
him decrease his pain medications safely.
Assisted suicide is now legal in some
countries and some states. There are
patients and there are healthcare providers
that would have no qualms in making this
a part of end-of-life care. Others may find
it disturbing or even morally abhorrent. At
this time it is a very controversial part of
care. If the patient or a medical professional
disagrees with this, then a new therapeutic
alliance with a different healthcare provider
may be necessary.
Family members may have been very
protective and even somewhat authoritarian toward the patient before she entered
end-of-life care. This type of role-reversal
may be the hardest on them. They must also
give her wishes priority—within reason, of
course. They should treasure the time they
have left with the patient as best they can.
In our society, dying costs money. Quite a
lot of it is spent in a patient’s final days in the
intensive care unit, or on that last trip to the
emergency department.
Those who know that they are at the
end of their lives often have the luxury of
deciding where they get to die. If the patient
desires it, he can die at home surrounded
by family. This is less costly than weeks on
a ventilator. If a patient desires it, though,
emergency care can be sought. That adds to
the cost of dying and ties up resources, but it
is what the patient perceives as quality of life
at that time.
Hopefully healthcare providers—and
family members—have very carefully gone
over directives for end-of-life care in multiple scenarios with the patient. As mentioned
Healthcare professionals must decide, along
with the patient and his family, when care
switches from curative to end-of-life care.
above, living wills and power-of-attorney
designation can help ensure that a patient’s
last wishes are carried out as she sees fit.
This also saves money and resources by
not providing care that the patient does not
desire. If a patient at the end of her life wants
everything done for her should she become
obtunded, then it is the responsibility of the
medical professionals to help her understand
the ramifications of this. If she does not
change her mind, so be it.
Both healthcare providers and family
members can sound very callous when
mentioning the cost of healthcare around
or concerning a dying patient. The natural
inclination for both parties is to want as
much healthcare as possible for someone
who is critically ill, even if he is dying. If no
advanced directives have been given, then it
becomes the responsibility of the patient’s
family to communicate what they think his
desires for end-of-life healthcare were. The
medical professionals can help the family,
once again, to understand the ramifications
of these decisions for the patient. In this
case, if the family wants more instead of
less healthcare, then not knowing or having
the patient’s delegated desires, the family’s
desires should be followed. Cost should only
enter into the conversation if the healthcare
providers are asked by the family about it.
In the end, someone is going to have to
pay for end-of-life care. The patient will not
need to worry, since he will be dead. His
estate will have to pay what any insurance —
Medicare or otherwise—does not.
Anything that is not paid by the patient
or by insurance carriers will either be paid
by state programs or swallowed by the
medical professionals and healthcare facilities involved in her end-of-life care. These
costs are passed along to society as a whole
through increased taxes, decreased services,
and increased healthcare charges.
The end of life is just as important a
part of life as any other portion of it. In our
society, for a variety of reasons—including,
ironically, better healthcare—dying may be
by far the most expensive part of our lives.
People want to die with dignity. They want
the quality of the last part of their lives to be
just as good as all the parts that came before.
Deciding beforehand where and how they
want to spend the end of their lives, along
with the input of medical providers and family members, can go a long way in making
sure this happens. Many such patients would
choose to die at home surrounded by loved
ones in hospice care rather than in an intensive care unit. This not only saves society
money and resources, it also increases the
quality of life for patients by allowing them
to choose their end-of-life care as they desire
it. It is grim to associate dying with a winwin scenario, but perhaps in this case it is
strangely appropriate.
About the Author
Charles G. Ison, MD is a native of Lexington.
He graduated from the University of Kentucky
College of Medicine and did his residency
in Pediatrics at the University of Florida.
Currently he is practices at Pediatric &
Adolescent Associates in Lexington.
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