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Comment by cameronh90 | Hacker News Reader

The way we care for the elderly in hospitals is not working and cannot continue as the population ages. Issues like the one raised are just the surface. We are spending an ever increasing fortune to keep elderly patients alive for just weeks or months, often with poor quality of life.

What this and the article is pointing towards, is that we need to get better at assessing when it's time to move from curative medicine to palliative care. This is not just about advancing medicine, but about our culture and attitude towards the (current) inevitability of death.

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I did a rotation at a wealthy Bay Area hospital where they routinely put stents in patients in their 80s. Thought of reporting them to medicaid for overbilling but most of the pts were private pay. Hospital has over $4 million dollars worth of art on the walls and a $500k koi pond in the lobby.

I live in the UK, so my experience is in NHS hospitals, which are rather more frugal in their decor.... however over-treating patients in their 80s is little different on this side of the Atlantic.

It's not done for a profit motive in general here, but more that nobody loses their medical license, and no NHS trusts get smeared in the gutter press, for trying to "save" a life against all hope (see the controversy surrounding the Liverpool Care Pathway).

The lack of any legal route to assisted dying is also a problem. Even if that was introduced here, it would probably only cover people with a specific terminal diagnosis, not the more common scenario in the elderly of repeat curable problems.

> The lack of any legal route to assisted dying is also a problem.

Euthenasia is a contentious topic, rightly so in my opinion, and is a seperate issue to regaining a balanced view of how and if we should treat the seriously ill when the treatment may harm them as much as the illness.

I think there needs to be an acceptable palliative care option rather than attempting to extend the life of someone in their 80s. That's not really euthanasia. Accepting death is inevitable and making the last days of life comfortable seems like a better use of money than an operation that will give the patient a few more years of frailty at best.

I would want to live another few years even being frail in fact most people would.

most people would

You're wrong. There are many factors in play (family, friends, isolation, stress, money, pain, etc) around the individual's choice, but studies often find that the majority of older people would prefer a palliative approach to end of life. For example https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821585/ Sadly there aren't many studies around this topic. It's important, especially when so many people assume that older people just want to 'not die' rather than listen to what they actually want.

I personally knew a guy who was diagnosed with cancer and instead of treatment chose to spend his last few months with his family and then just die. This was in Germany, so all healthcare would have been payed for. A major reason was minimizing suffering for his family, having a good conclusion instead of prolonged suffering with unclear end date.

My uncle got diagnosed with cancer at 93 and his initial choice was similiar (I have to die of something in the end). But the family convinced him to try the therapy and it worked. He is still after two years alive and relatively well.

Different types of cancers are entirely different diseases with different outcomes. Your uncle was part of the lucky ones.

I would rather the resources to keep me alive in a frail state go to benefit the younger and future generations. At least the option for me to do that comfortably should exist.

Have you experienced frailty before? I have had a chronic illness that intermittently puts me out of commission as a relatively young person. Imagining living that way as an already aged senior sounds like torture.

I have had grandparents live into their late 90s with a decent quality of life. I think they appreciated life extension pas their early 80s.

That's where it gets tricky. I don't think anyone here has said patients in their 80s shouldn't get any life prolonging treatment.

I think patients should be able to choose this if they'd like... or choose euthanasia. Or choose life-saving options that are available.

I'd personally rather live so long as I know better. Death might be inevitable now, but that isn't necessarily a set thing. Folks are working on having different sorts of existence and working on extending life and things like that. Sure, some of it seems like a pipe dream now, but who knows when some weird breakthrough will happen. I'll take my few years, and resent anyone trying to take them away - but your few years aren't mine to decide what to do with.

Besides, not everyone in their 80's is necessarily frail. Some are frail sooner, some later.

1. Most people like to live.

2. Most people at the bitter end are past the ability to make decisions.

> but your few years aren't mine to decide what to do with

Depends who is paying for them. Voters certainly can take Medicare away, or implement a triaging criteria.

I do not think that matters. Of course, I'm probably not of the same political views as you and fully support taxpayer-funded health care. All of it, including end-of life. Voters shouldn't be the ones deciding that care: Doctors should.

I'm generally against doing procedures that won't really add life to folks - especially weeks. Years, though? That's years. Folks can be frail yet able-minded and so on. It doesn't really matter to me if someone needs to have some assistance to live, regardless of age.

Triaging criteria already exist. It is really a shame that insurance companies and businessmen have their hands in it instead of doctors. But I don't mind these criteria: They are, in general, for emergency situations instead of, say, routine gall bladder surgery.

I also support taxpayer funded healthcare, but I realize that taking care of each and every old person in nursing homes and keeping them alive as long as possible would consume a disproportionate fraction of the nation's resources, especially in a population with fewer and fewer children.

And the people triaging at insurance companies are doctors and pharmacists themselves. A doctor not employed by insurance companies is also a "businessman", considering they get paid more the more they treat. No one is exempt from conflicts of interest, but since US voters didn't want "death panels", they get to deal with prior authorizations.

It's the same function done by the NHS or government in any other country.

If someone wants to die, let them fucking die. The fact that people consider this "contentious" is utterly ridiculous. How can you possibly justify telling other people to go on living if they don't desire to do so? Seriously, mind your own fucking business.

This is why I consider it “contentious”:

«On February 13, 2014, Belgium legalized euthanasia by lethal injection for children,» from [1].

«Even the controversial head of Belgium’s euthanasia commission is concerned that a well-known Belgian psychiatrist is allowing too many of her psychiatric patients to be euthananised,» from [2].

1: http://www.patientsrightscouncil.org/site/belgium/

2: https://www.bioedge.org/mobile/view/belgium-euthanasia-docto...

'The law states a child would have to be terminally ill, face "unbearable physical suffering" and make repeated requests to die - before euthanasia is considered. '

https://www.bbc.com/news/world-europe-26181615

Perhaps the law is not being applied this way, but I think the idea here is "this poor child is in agony with no hope of improvement and keeping them alive is torture in a sense" - not "let's take terminally ill children lightly"

> If someone wants to die, let them fucking die.

That is not what the assisted suicide debate is about. The debate is about the right to kill someone who cannot do so themselves.

Not to mention, it’s not exactly clear as to who is able to make that decision.

I’ve never thought of that as the debate. Not providing care is not killing someone. We already do plenty of that in the US. The debate is about giving someone a quick, painless death via the application of certain medications as opposed to letting someone waste away painfully.

Counterpoint: Bernie Sanders is just 2 years short of 80. He seems to be a vigorous man who had a temporary medical setback, then was restored to full health by stent insertion.

Jimmy Carter was treated for brain cancer in his early 90’s.

https://www.cancerresearch.org/join-the-cause/cancer-immunot...

He’s still alive 4 years later.

So we are using extremely carefully selected individual examples now to come up with policies for everyone? Right then.

And no, just because something works to "save (or extend) one life" does not mean it should be tried for everybody, because "hope". If you read the article - which says nothing surprising anyway - you balance your very few successes with lots and lots of bad cases. For some few to live longer a lot of people have to suffer more.

Completely orthogonal, but since the path this thread took shows people care a lot (too much) about individual examples, I saw this more than once in my own family. My 94 year old grandmother broke here hip, surgery was ruled too dangerous, so she was driven back to her retirement home - where she only spent her last year, when care became too difficult at home - and spent the rest of her days just lying in her bad waiting to die. There was no good option left. That's just how it is near the end. I'm just saying this to show that I'm not talking about something that I only know from discussions such as this one.

Also, both my grandmothers (who both made it into their nineties) had surgery in their 80s and both suffered significantly. Their brains were not the same afterwards. Anesthesia is not easy on the brain, even on top of any stress of the surgery itself on the body. There was a significant difference in mental abilities in both my grandmothers when comparing how they were before and after their surgeries (both had them for broken bones that occurred due to age related osteoporosis). And they both had pretty good starting points, others are much more frail at those ages.

Two years ago my dad (now 81) had a stroke. The hospital was trying to "let him die", so after a few days he rather left the hospital for an exam at a university he is studying (he passed it, but he had to pause the study for a year until he recovered from the stroke).

There's a difference between inserting a stent during a cardiac event as a treatment, which is what Bernie had done and routine stent insertion of stable patients, which is what I assume the gp was talking about.

You mention the art on the walls and the koi pond as if they are spurious examples of unnecessary spending, when many studies point to the great value in such environmental factors in healing.

If you’re spending millions on art, you’re a museum, you’re being swindled, or you’re trying to find a clever way to shift your cash around.

And I doubt hospitals are debuting rediscovered Van Gogh works. Buying affordable works from local artists can fill a massive hospital for well under a million.

Or Van Gogh prints, for that matter.

I guess there are cheaper ways to achieve that. I think they are more to impress people.

The responses here decrying the cost of the artwork and suggesting replacement with prints denies any and all value to artworks as profound objects, and could easily be as mis-applied to museums themselves.

For those lacking understanding of the value of art in this context here is a good recent piece of research with many useful references: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5328392/

I think the real issue is that these folks are profiting so much as to afford the art while folks have trouble paying for hospital stays. There are so many ways to get original artwork on the walls for a much cheaper price tag, after all - and things get even cheaper if one looks into prints.

"Hospital has over $4 million dollars worth of art on the walls and a $500k koi pond in the lobby."

That's one thing I ave noticed in a lot of US hospitals and doctor offices. Everything is very shiny and new and costs a lot of money.

It's the invisible hand of the market at work. Obviously, patients are preferring to pay premium for treatment hospitals with expensive art and swanky facilities.

I wonder if they preferred it less if they had a way to find out how much the hospital costs before treatment.

That would make sense, at least for the people paying the costs themselves.

The economics change with insurance coverage. Once I hit my deductible, why do I care how expensive it is? At that point, might as well get my money’s worth out of my insurance company.

The last time I need non-routine care, the only thing I cared about was:

1. Is this doctor good?

2. Is this doctor/hospital in-network?

"The economics change with insurance coverage. Once I hit my deductible, why do I care how expensive it is? At that point, might as well get my money’s worth out of my insurance company"

The money doesn't come from nowhere. If everybody thinks like this, your insurance costs more money.

If you don't pay for your insurance personally, how about just straight up being paid more by your company?

Many people do think like that, and it is likely a significant contributing factor to the cost of health insurance.

I do pay for my insurance personally. Health insurance law is somewhat different than most other forms of insurance in that the premium cannot be increased no matter my frequency or magnitude of previous claims. [0]

My marginal use is a merely a rounding error in the context of my health insurer's outlays. Nothing I could do would personally affect my rate. The aggregate of many thousands of people's use determines my rate, and for that, the tragedy of the commons is fully in charge.

[0]: https://www.healthcare.gov/how-plans-set-your-premiums/

When you can't make a profit on paper you have to piss that money away. Executive salaries and fancy pants facilities that the well to do like looking at are the typical ways of doing this.

The basic concept of a commercial insurance based health system is that people basically pay for their own treatment. Thus wealthy people pay top dollar and get first class treatment at world beating institutions, while over 20 million Americans have no health cover whatsoever, and many of those on cheaper plans that can't afford lawyers get cheated out of crucial treatment.

Totally agree.

Most surgeons are mindless robots. So immersed in their craft, full of themselves and disconnected from the rest of the population that they don't pause to think too much about what they are doing.

Not unlike any other profession with hyper specialization. It takes other members of the team or group to reign them in.

The job involves a whole lot of decision making surrounding ambiguity and uncertainty, and there are certain personality types who are totally unfit to handle such decisions. They get pushed into the room because of other skills and mindlessly do what they are programmed too.

Few months back I saw one jackass more interested in showing a family video clips taken of the surgery on their 80 year old mother, than actually talking about what they had achieved through the 8 hour reconstruction of all her internals. She passed away a few weeks back after all that pointlessness.

After many bad experiences with family and friends, I always ask the specialist how many such ops the team has done in a year. And then, how many have long term positive outcomes. And then, if they can put me in touch with someone who has been through it a few years prior. These days its easy to dig up this information.

> Most surgeons are mindless robots. So immersed in their craft, full of themselves and disconnected from the rest of the population that they don't pause to think too much about what they are doing.

This is an extraordinary assertion. Having watched my two elderly parents getting excellent -almost loving - care from surgeons on the NHS, I find it quite an offensive one. In both cases they sat down and spent quite a lot of time going through the pros and cons of surgery at at their advanced age. Dad decided to go ahead with a particularly ticklish piece of back surgery which gave him another 7 years of mobility and independence, even though it wasn’t fully successful.

I’m sorry that you had such an appalling experience. It’s not universal.

The stats you ask for are freely available in the NHS. The surgeon carried out the procedure on dad, knowing full well that it could quite possibly worsen his mortality figures.

I completely agree. In Denmark I've experienced more than once that our healthcare system lay the pros and cons so the patients and families can make a reasonably informed choice. They straight up refuse to perform surgery on some as they are deemed unfit for the procedure.

Well you guys better protect that system cause where I live it's like a factory assembly line with well programmed robots herding people through without too much thought to long term outcomes.

I have had good experiences only after putting in a lot of research (that too after some painful lessons). And thats an option if it's not an emergency.

I have had to deal with a couple emergencies over the last couple years, where decisions had to be taken quickly. And I have seen both good and bad outcomes. The bad outcomes almost always are some guy at the ER acting as if palliative care is some unimaginable option.

They frame it simplistically "We have to move patient to the OR or they will be dead in X hours/by tomorrow etc". Just because it's possible to operate doesn't mean a surgery has to happen. Especially on elderly people.

It creates all kinds of cascading problems if it's a bad call. Good outcomes are possible but it needs a certain personality type and experience.

Well you're basically asking the surgeon how many surgeries she's done, how good she is at it and saying he's too obsessed with surgery. Of course there are jackass surgeons, but most surgeons don't want bad outcomes; because they believe in what's best for the patient if you are an optimist, or they are worried about bad outcomes (which is monitored in most western countries) if you're a pessimist.

>What this and the article is pointing towards, is that we need to get better at assessing when it's time to move from curative medicine to palliative care.

From personal experience, the healthcare system is also bad at determining when it's time to move from curative medicine to palliative care.

We need to get better at elderly healthcare in general.

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