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"The Royal College of Obstetricians and Gynaecologists (RCOG) says the huge efforts to save babies born under 25 weeks are hampering the treatment of other infants with a better chance of survival and a healthy life."
http://www.timesonline.co.uk/tol/news/uk/articl...
Turns out <25 wk preemies have a surprisingly good chance of survival, it's the "health" part that's the problem.
Seems like you enjoy pickin on post partum moms and 92 year old Little old ladies with Cancer...
I sense some unresolved Women Issues here...
My Issues, not yours,
I used to beat up people like you...
Frank
Granted, with metastatic disease her survival is probably pretty limited. But given that chemo is not the same as it used to be, saying no to any and all chemo seems a bit premature. Even in a 92 year old.
If they have the money to do so and can find a doctor willing to perform whatever procedures are needed, I see no fault in that, and no one should be able to tell them that they can't... not government, not other physicians.
All I'm saying is, regardless of how futile the care is, if there are two willing participants, one whose willing to pay for it themselves and one whose willing to provide care for them, no body should be able to stop them from doing so.
Sorry, that's the reaction I have whenever I see misinformation about the Canadian healthcare system promulgated.
As a physician and a Canadian, I can tell you that the physicians make the choices. The government pays.
If I discuss with your 92 year-old grandmother who has all her marbles and knows what to do with them what her situation and expectations are, and we come up with a reasonable plan which includes chemotherapy, then the gov't pays.
They don't refuse to pay. The don't make the patient pay and then argue about this bit or that bit when reimbursing the patient. They don't call me up and say, listen, about this 92-year old cancer patient. They PAY.
In other words, don't believe every bit of propaganda fed to you.
I don't think anyone can say how long a patient like this would survive with vs without chemo. Those studies have never been done. To assume that doing chemo in this patient has a survival benefit is premature. The last I read the mean survival for patients with metastatic breast cancer is about two years, with a huge variation from a few months to years.
From what I understand absolute survival by doing chemo may be extended from several months, up to a year.
Medicare was never intended to prolong the life of a 92 year old so she could live to 93 with chemo therapy. The money is simply not there for this benefit to last forever. And she didn't pay into the system to get chemo at 92 years old. She paid in to keep her from dying. Not from dying
Do we have an obligation as a country to bankrupt ourselves while trying to keep a 92 year old alive for 4 extra months? Or do we have an obligation to accept reality and provide comfortable hospice in the last few months of her life.
We already choose to let thousands of transplant candidates die every year because of the rationing process from limited resources. We treat nontransplant care as if it is unlimited in financial resources. It's not. It's 85 trillion dollars in the hole.
Please don't blame me for telling the truth. What physicians need are more gut wrenching truth talks with their patients.
if it’s not terminal, it resumes in patient choice I guess
Chronological age vs. real age, that patient is not terminal, at least you can’t be sure.
As technology and life styles improve, there is an exponential growth on lifespan, 200 years ago people used live up to their 4x - 5xs at most. as time progress, it changed, now we see how many old protocols are modified, you now use fibrinolitics on older patients for stroke, surgical techniques (ex femur fractures) that were applied on younger are using on older people, right now.
"When the Medicare National Bank (MNB) was established in the 1960's nobody could have predicted that 92 year olds would be getting chemotherapy and surgical ports for metastatic breast cancer".
Exact, that was 50 years ago, people at that time died from cancer, regardless of how young or healthy they were, world is dynamic; Medicare can’t be exactly as it was before. There will be the day when people won’t get chemo or surgery for cancer, surgeons will be considered as butchers, and the cancer patient will only need a pill.
I know how expensive can be, what you consider as unnecessary, and maybe it`s , but keep in mind you are avoiding, all ethical issues related to the subject, while I see your precious economical insight valuable, you still discard the ethical part, whether she receives chemo or not, she will still need to receive palliative care, either way she is going to spent, she got the right to choose, ethically speaking, since there is not protocol that forbid such thing.
This lady might get some extra time, but at what cost to herself and her family in terms of quality of life? She will have to go to chemo appointments and devote 1/2 days to receiving chemo (depending on the type). Chemo makes you sick. Even though there are new and "different" types of chemotherapy now, people still struggle with nausea and vomiting...and don't forget the fatigue. Fatigue meaning you can't/won't get out of bed. Mind numbing fatigue, just getting dressed takes it's toll...never mind taking a shower. Chemo can cause lasting numbness to hands and feet (sometimes, this gets better with time).
Chemo makes you sick. With nausea and vomiting, good luck working up an appetite. Chemo changes the way food tastes. Your favorite food just doesn't taste good anymore. If you can't eat, you get weak. Now you're not only fatigued, you're weak from not eating.
All of these lovely chemo side effects cuts effectively into the time your life has been extended. Is it worth it?
I'm a hospice nurse, formerly an oncology nurse.
And, if the chemo doesn't make you sick or doesn't make your hair fall out....it's probably not killing cancer cells, either.
Never mind the cost in $$$.....it's a horrible way to spend the last months/weeks of your life.
Now, if your argument is that it is not worth X number of dollars to give that 6 months to anyone, than so be it but my understanding of the QUALY system is that, as long as the function is the same, age does not matter.
And I will re-iterate unless you can prove that the therapy does not work as well in the 90 year old, I guarantee you that it is illegal on the face of it to withhold it from the patient. I don't see us overturning the age discrimination part of the ADA over as long as the AARP is one of the largest lobbies in the country.
It seems that you are either making a medical judgment that the therapy will not work the same or a moral judgment that the 90 year old does not deserve the same chance at life extension for palliative therapy. An argument could be made about CURATIVE therapy in that even if you "cure" the 92 year old she would only probably live another 4 years (thus raising the cost per QUALY) but this does not apply to palliative chemotherapy -- i.e. each person is only getting 6 months anyway so the cost/time is fixed.
If the 92 year old woman has supplemental insurance or wants to pay out of pocket for her care that's fine, but personally I'd rather have my public dollars go to a 20 year old with lymphoma who doesn't have insurance.
How do I know this? As a pharmacist, I am one of her providers & she does not have Part A nor B.
So - are you casting judgement against all 90yos? If so, you are an age discriminator. I am probably as old as your mother & from what I have read, you are in no way fit to be a parent - even if your insurance covers your IVF or not! If your insurance paid for any of it, I am incensed since I am probably in the pool which underwrites your risk group. You, sir, are a tremendous risk to the next generation!
Leave my mom alone!
I can all but just short of guarantee you that the prognosis of a functional 92 year old with metastatic breast cancer is much worse than the same cancer in a functional 57 year old. When you start with old organs, you have less to work with. A 92 year old will not respond the same to chemo as a 57 year old. That's like saying a functional 92 year old admitted to the ICU with septic shock has the same recovery chance as a functional 57 year old. Not even close.
While functional status is important to making medical decisions, to deny age as a contributing factor in making appropriate treatment options is to deny biology.
Why do we not give 92 year old functional retired nurses with end stage liver disease from a Hep C induced needle stick a liver transplant? Is it because we have limited resources? Is it because 92 year olds wouldn't do well with a liver transplant? Show me the data that suggests a 92 year old should be denied a liver transplant for medical reasons and I'll show you the same data on metastatic breast cancer. The studies haven't been done.
What we have with liver transplants is rationing. It is rare to "offer" a transplant to someone over 70 years old. Why is that? Is that age discrimination? Is there strong clinical data to suggest liver transplants in those over 70 do not do well? If there isn't data, should they not be denied an offer of a transplant until that data exists.
92 year olds are being "offered" chemo. 92 year olds are not being offered liver transplants. What's the difference? We choose to accept the denial of liver transplants, but not the denial of chemotherapy?
Why?
When including the expenses of complications, disease progression and actual chemo costs both run into the hundreds of thousands of dollars, perhaps millions.
How can you justify the rationing of liver transplants, starting all the way at 70 years old, but not justify the rationing of chemo in a 92 year old?
Do you believe the resources to "offer" chemo to a 92 year old are unlimited? If so, I would refer you to the 85 trillion dollar in the hole Medicare has promised to pay but has no current ability to fund.
What's wrong with not offering chemo to a 92 year old if we aren't offering liver transplants as well. The decision to offer a therapy is not the patients decision. It is the physician's decision. The patient can choose to accept it or not. The physician does not have an obligation to offer all therapies all the time.
For example. A patient may want surgical resection of the metastatic lesions. The physician may not offer it. A patient does not get surgical resection if the physician will not perform it. Part of being a doctor is making the best possible recommendations on the available data.
There are many times a year I don't offer patients therapies that my education and experience and the data suggests a lack of efficacy. I have no obligation to offer a therapy I feel is not indicated. If that means a patient dies, that's OK because natural death is a natural process of disease. It's not because my failure to offer therapy caused their death.
When I recommend hospice care, I am recommending against further medical treatment. By default, the recommendation for hospice denies the patient my offers for other medical care. I do this because my medical opinion says that further interventions have no medical value in their care. That is not only not a bad thing, but saves the patient unnecessary involvement with physicians who will do things to patients because they can, not because they should.
Linda, deep down inside that hatred of yours, I'm sure you're a good person.
Not that I'm for wasting precious Medical Resources, get back to me when they stop spending money on AIDS research/treatment...
OK, sure it would have been nice to get a few more Albums out of Freddie Mercury, but I could do without the last 18 years of Magic Johnsons work...
How many generic prescriptions had to get denied to pay for Ted Kennedy's Gamma Knife procedure??? And if I ever get a Glioma thats what I want since he's lived about 10 times longer than average...
Truth be told, the old bastard probably didn't even have a tumor, just your run of the mill DTs, but how would that look in the NY Times???
and do you ever TREAT anything??? seems you spend 90% bragging about not treating stuff or badgering some post partum mom for using a perfectly legal product, a product that funds a good portion of pediatric care in this country...
Is your complaint about this the low likely return (spending hundreds of thousands of dollars to treat someone who is likely to die within a year or two of something else, even if her cancer is cured)? Or about her receiving futile care that's just going to put her through the wringer, after which she'll die of her cancer more-or-less on schedule? Or is there some other issue here I'm missing?
The fact of the matter is even though we are desperate to hide our age with Botox, Fillers, plastic surgery etc our internal organs are still old!!!
When I did some auditing for my Ex I read many times over the halting of any active care and D.N.R's for people over 80. Maybe a cost thing, maybe just because they are really old and there older organs cannot stand up to any rigorous treatments or surgeries.
My Grandmother in her 90's kept saying how tired she was and could no longer be bothered waiting for the Queens letter. She died at 97.
I suppose its how desperate a person still wants to live.
I think that if you do palliative treatments that will improve the quality of remaining life, I get that. If a hip fracture surgery will save a patient excruciating pain, then it is necessary. But if, like your great grandmother the treatments are worse than not having them, even if they can extend life, why put someone through that?
We spend more money on the last 6 months of life, than the whole life. And while the money issue is there, that is not what is most important. I don't think it is right to expose an elderly patient to the kinds of side effects of chemo. For what? A few extra months of misery? Another year? Can I quantify what that year means to friends and family? No. However, when you will likely be dead in a year no matter what you do, I think the most ethical thing to do is spend that last year in as good a state as possible.
Should we put a 37 through the same therapies? At least you can tell a 37 year old that you have data that suggest giving X drug has the opportunity to help you in Y ways It can also hurt you in X or Y ways. How many double blinded randomized trials are powered to give you good prognostic data for 92 year olds reaching the last few months of their lives. The answer is none.
You can't tell a 92 year old what you expect to happen based on studies done on 37 year olds. It's not good medicine, nor is it a physicians duty to offer care to a patient that is unproven and could potentially bring more harm than good.
Look, I agree with you that it makes no sense to be slamming lines and vents into and whaling on the chests of elderly patients who are clearly terminal and spiraling rapidly downward, but Buckeye's patient was not terminal; she was functional. Buckeye confirmed that the patient's oncologist had explained the side effects to her. And, since she IS functional, she is also capable of deciding to stop chemo if she finds the side effects intolerable or simply not worth suffering through for the hope of living a little longer. Where I disagree with you is on the assumption that simply because this patient is 92 years old, she has lost her autonomy and her right to make her own medical decisions.
Really, the doctor cannot even properly counsel to the patient about the side effects a 80-90 year-old person will have from chemo. It will not be the same frequency of side effects quoted in the drug manuals. Instead of a 20-30% chance of infection, is it 40%, 50%, 60%? We know that it will be higher, but not how much. So how is your 90-ish year-old healthy patient going to make an "informed decision" about the risks and benefits of chemotherapy. She cannot because no one really knows. It is not an argument about whether or not she has a right to decide. She can't decide correctly if she doesn't have the right information. Do you encourage us to lie to our patients?
And do you know the reason why no one knows? They have tried multiple times to do chemotherapy studies in elderly patients, to compare placebo vs. chemotherapy with supportive care to both groups. You know what happens to these studies? They never get enough people. Why? Because patients are afraid to end up on the chemotherapy option.
In this woman there is just as much good evidence that an apple a day will help as a cycle or two of chemotherapy. People like to get on their high horses and argue about what is ethical, and that people have a right to decide. But you forget you can't make a good decision off of bad information. Chemotherapy is poision (for the most part). It kills cells. You give the same amount of poision to a young cat and an old cat. Who is going to die first? How about a dog or a mouse? It's the same with people.
Okay, you say, then give her less chemo... Well how do we know how much less to give? Wait, we don't know, because it hasn't been studied. What if we give her a low dose and it doesn't help? You see where this is going.
Oh, and by the way. Just because she is a functional 92 year-old with metastatic breast cancer, she is still "clearly" terminal. She will die from her disease, if something else doesn't get her first.
And even though there is no evidence, I've seen what chemotherapy does to elderly people, even the functional ones.... Just in my own experience.
-A lung cancer Doc
The notion that we can predict who will develop which side effects from chemo is absurd; while RCTs may show a 20-30% chance of infection in the studied population, this has little predictive value regarding the actual rate of infection in any individual, regardless of age. Instead of deciding for the patient that she can't handle chemo, why can't you tell her that studies show x% chance of infection but these were conducted with a younger cohort and her chance of infection is likely to be higher, by an unknown degree? If your clinical experience with patients similar to her tells you that she is likely to do very badly on chemo, why can't you give her that information so she can make a better decision? If, as you say, there simply isn't enough information for the patient to make an informed decision to try chemo, there simply isn't enough information for you to make an informed decision to withhold it, either.