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I haven't had a chance to read the article yet but as a physician--yes we often overtreat at the end of life. I have had horrible experiences basically torturing patients with repeated invasive procedures and disease-focused treatments who have designated their decision making to a family member who is unable to accept a recommendation for hospice care from the treating physicians. In some cases this is motivated by religious beliefs that "everything must be done" to save a life no matter how much pain or suffering is causes. It's morally distressing.

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There's the "everything must be done" crowds, but they're not (just) religious folks. There's also the bean counters (more tests/treatments = more revenue), and the paranoid about litigation folks who worry more that it's easier to explain action than inaction.

My grandmother went into a facility for palliative care in the last few weeks of her life. We saw all of these folks, and it was a struggle to reign them in.

There's a whole lot of really terrible behaviour that's done just because it makes someone more money or someone's job easier, and if it results in actual pain/discomfort to the patient, who cares.

I wouldn’t characterize it as “paranoid about litigation”. Lawsuits against physicians are common, and you absolutely have to consider the small but real risk of having to defend your actions in court. I’m a physician and see this play out all the time, and there’s a reason malpractice insurance is as expensive as it is.

Just because you're paranoid doesn't mean they're not out to get you. Justified paranoia is still paranoia.

No it quite literally isn't

How expensive is malpractice insurance, as a proportion of your salary?

Depends on the specialty, but roughly $500–$1500 (higher for surgeons and proceduralists; ~5% of your salary). However, if you work as an employee for a hospital or a large group practice, you don't pay for malpractice insurance directly. The institution covers it, but obviously it will indirectly impact your salary.

Malpractice can be $30-$90k/year for an OB-GYN. Hospitals may cover part of this, but a private practice may not. This is a huge percentage of an OB-GYN salary, and creates negative career satisfaction across the specialty. (As if medical school debt and the residency hazing process were not enough.)

In private practice, OB's also often have to pay for their own tail insurance, which also means if they quit the practice, they have to pay malpractice insurance (basically in perpetuity) to protect against late-arriving lawsuits. This also traps physicians in their job/specialty and makes early retirement challenging.

It's a great system. /s

I would question whether extra treatments for an end of life patient is really a profitable venture for a hospital vs the opportunity cost of more lucrative elective stuff.

End of life treatments are, I assume, very profitable, because either they'll be covered by insurance, or they'll be paid by the deceased's estate. They'll probably get paid the full asking price rather than having to give a discount too.

I wouldn't argue they aren't profitable, but there is a good chance Medicare is covering it, which is substantially lower reimbursement than private insurance.

If they have a limited volume of beds, I'm sure a focus on profit would drive a private patient getting care versus an elderly Medicare patient.

If the estate can’t pay then the debt is just written off though.

That aside, ability to pay is not going to be the top consideration of the baseline profitability of a procedure.

I don’t know any specifics though.

But most people do die with an estate of some kind

I’ll counter with my own anecdote… My BIL passed earlier this year after a life of alcohol and drug abuse led to organ failure. He made peace with his fate and was ready to go. But, the hospital placed him in a coma and on a ventilator. Then made it extremely difficult to have him moved to hospice and removed from the vent. It took days of phone calls, lawyers, and social workers to allow him to die. This caused much unnecessary stress for my wife, who was the only family member present. This was at a facility run by Floridas largest hospital group. I wonder if it was profit or their own religious affiliation that caused this? Either way, it wasn’t as simple to let a family member pass on as it should have been.

Most times when this happens its because the patient doesn't have these goals clearly documented, in my experiences hospitals are willing to follow the wishes of the patient. If the patients wishes aren't clearly documented that's when it gets tricky.

Florida's largest hospital group has a religious affiliation? Ugh. We can be crititcal of goverment-run healthcare, but at least that headache is avoided. I live across the street from the one hospital in my small city. I think there would be protest marches if it ever proclaimed a paticular religion.

Not just any religion, it’s a Seventh Day Adventist Hospital (an offshoot of the Mennonites, who believed the end of the world was predicted in the Bible). This has all sorts of weird implications; from my memory, they can’t serve caffeine on the premises. There’s a giant painting of Jesus guiding a surgeon’s hands in the front of the Orlando branch when you walk inside.

I grew up overseas. All the hospitals were technically "islamic" but the great thing about that was zero religeous paintings. There were no crosses hanging over beds, but neither was any other image. Christians felt as welcomed as anyone else. The architecture and decoration was agnostic. Even the attached mosque was basically just a square room pointing in a strange direction, and was open to all peoples.

Isn't that a direct result of the Islamic belief that man made art is offensive to God? The same reason mosques are decorated with geometric patterns and not "art".

I think the prohibition is against depicting living things.

That’s just Islamic aniconism: https://en.wikipedia.org/wiki/Aniconism_in_Islam

Islamic religious art na look agnostic … if you don’t know what you’re looking at.

Of course, without context Christian religious art is a lot of plus signs, moms with babies, winged babies, weird bonnets, and torture porn.

As someone who was on the other side. I will say that these decisions are made by patients and family on a daily level, one at a time. It is hard to step back and look at a big picture and say ok today is the day when we pull the plug on the treatments.

I do agree that a final 'big picture' decision needs to be made but its hard to get that mental clarity when you are in the eye of the storm.

Also, I've personally decided to go by euthanasia after I lose my independence but I am also not clear at what point I should make that decision. I am worried that I will delay that decision and end up in a situation where I lose my faculties to make that decision.

“ I am worried that I will delay that decision and end up in a situation where I lose my faculties to make that decision.”

Same. I have cognitive issues from m.s. and intend to move somewhere where my desire is respected. My quality of life already sucks, so I may make the decsision sooner than would normally be expected.

> I am worried that I will delay that decision and end up in a situation where I lose my faculties to make that decision.

I'm concerned about that too. Broadly, the circumstances in which I'd want to get it over with painlessly are circumstances where it's hard to see what I could do about it, like if I'm immobile in a hospital bed. I want a stash of Nembutal in my medicine cabinet, that's the drug recommended by Exit International; but I can't get it. You sometimes see sellers offering it on dark markets at $600 for 10g, but typically they have zero trades and zero reputation.

Go to a big city and get a bindle of heroin. Or fentanyl on the dark markets.

AFAIK, most "opiate deaths" are the result of vomiting while asleep.

You are incorrect. Opiates slow your respiration and you stop breathing. You are probably thinking of alcohol deaths.

No, You're thinking of alcohol deaths. Opiates deaths are caused by opiates slowing your breathing and eventually stopping it.

Well, anecdote: It's usually said that Jimi Hendrix died of a heroin overdose. I believe the truth is that he died from inhaling vomit.

Jimi Hendrix neither had alcohol or heroin when he died.

He aspirated his own vomit and died of asphyxia while intoxicated with barbiturates. Specifically, large doses of the sleeping pill Vesparax.

Opioids kill by slowing breathing, full stop. The medical term is "Opioid-induced Respiratory Depression." Narcan very rapidly reverses this, which is how it saves lives.

I feel bad for you having to deal with this stuff.

It is strange how they often cite religious beliefs, but if they firmly believe in "god" why are they always willing to go to such great lengths to prevent dying?

This is VERY unfortunate in Canada because these people cost the country a small fortune for no real reason. There was a story a while ago about an individual, 70+ and braindead, family fought and fought to keep him alive. I cant help but wonder if they had to pay, would they have continued to fight?

Health care wise Canada already heading down the drain. Trying to save few people should be the least of your worries in this department. Our fucking "servants" are doing stellar job.

Don't denigrate healthcare workers. They're most often doing the best they can.

I am "denigrating" our masters, not workers. And if you think we do not have huge problem in healthcare you've got your head firmly planted into the sand

What exactly is wrong? There’s no perfect way to run a huge system, but Canada comes close.

We must be living in different Canadas. It is getting worse every year. And the people responsible just keep raising their own salaries. "Heckuva job (TM)" they do.

What are the specifics? I’ve had great experiences, getting tests, seeing specialists, all for free

How do you see those as being "free" to you? Do you not pay taxes?

Yes, and far too much. I don’t get the doom and gloom about how the system is supposed to be collapsing though. Canadian health insurance is much better than the private insurance I had before I moved here.

Blaming just the patients and families is disingenuous. The incentives on the hospital, and doctor to overtreat are large and are an equally contributing factor.

Even in socialised medicine in western europe, this phenomenon exists, where the financial side of those incentives is much reduced as funding is much less directly tied to treatments.

You are very much mistaken, it is almost always the family doing this.

As an example:

https://www.canlii.org/en/on/onsc/doc/2017/2017onsc6511/2017...

[2] Following Shalom’s brain death his family had discussions with the staff at Humber River Hospital. They explained that in accordance with Shalom’s and their religious beliefs, Shalom was not considered to be dead under Jewish law until he stopped breathing and his heart stopped beating. Neither had occurred because he was on ventilator life support.

The hospital board ruled he met the guidelines to be considered "dead" - the family went to court to overturn this.

having been on the family side of this, i can personally guarantee that the people actually performing the procedures are against it. You should draw a distinction between a hospital and its doctors.

The doctors I know (roughly ~10 to ~15) are very much against “overtreatment”. The biggest problem they have is dealing with emotional family members.

There was also huge public fervor when the suggestion of funding mere discussion of end of life options was proposed with the Affordable Care Act:

https://pubmed.ncbi.nlm.nih.gov/26195604/

> The doctors I know (roughly ~10 to ~15) are very much against “overtreatment”.

Well of course that's what they think. Everybody is against "overtreatment". If they aren't against a treatment, they don't consider it "overtreatment", they just consider it "treatment".

Different people have different boundaries for what they consider "overtreatment".

Yes, but the point is that most doctors would treat less than patients and their families if it were their choice.

Hospitals and doctors are already fully booked, they don't need the additional work from overmedicating and overtreating patients in the last weeks of their lives.

Being overbooked is only the start of profitability. Just like airlines, once you have the customer inside your facility, you upsell. A patient recuperating/dieing in a bed nets only a daily rate. You need to then charge for as many additional treatments as possible.

Only in broken for-profit systems. This is a non issue in Canada and UK.

How? Canada is largely fee-for-service AFAIK, and the NHS mainly uses basically a big chargemaster for acute care.

This is not how hospitals work. There are always outliers that get news stories but most physicians do not wish to torture the dying.

No, wife is a doctor and she faced this many times. Doctors in such places are never working there for the money, if you consider them as such you are just projecting your morals on other people.

Its almost always the family - they just can't let go or have some christian type of excuse. Thus their moral weakness causes tremendous amount of suffering of their closest ones. And doctors have to obey family wishes, even if they personally wouldn't chose to, which is true for most doctors in such situations.

I've been been recently an unfortunate witness to one of the cases when its not closest family - grandmother of my wife was nearing her end, suffering tremendously. Her daughter, my mother in law who is a nurse and teaches nursing too and knows all staff of their hospital very well was looking for some strong painkillers ie morphine to help her with final sufferings, which went on about for a week. As her mom didn't want to die in hospital, nobody was willing to sign receipt, not even close personal friends (mind you we don't have opioids crisis in the country, so its not controversial to give them to 92 year old dying). Some folks from closer family or friends even said its fine to suffer before the end, to shorten/skip purgatory, or some similar religious bullshit. One of those times when I hated christianity and its believers more than ever, you know those. As they say, you will know true friends when you need them the most.

Switzerland is, as usually quite ahead on this - assisted suicide. Folks from all over the world come here to die peacefully, in full control. Ie Alain Delon is going through the process of getting this done right now. It doesn't cover all possible situations, but it gives certain control and dignity in times where most people have none left. Me personally, if facing such a situation, would do grand farewell gathering with all, sign my will and go somewhere in the nature to die quietly, ie jump from some cliff or overdose on heroin (first and last dose, but they say its quite an experience).

<<As her mom didn't want to die in hospital, nobody was willing to sign receipt, not even close personal friends (mind you we don't have opioids crisis in the country, so its not controversial to give them to 92 year old dying). Some folks from closer family or friends even said its fine to suffer before the end, to shorten/skip purgatory, or some similar religious bullshit. One of those times when I hated christianity and its believers more than ever,

I am not a religious person by anyone's description, but the choice here appears to be that of lesser evil. Final wish of a dying person ( along with their ability to govern their life ) here being that she did not want to die in a hospital. Wouldn't 'helping' her die break that wish? And more importantly, what if the dying person is ok with suffering?

<<Thus their moral weakness

It feels like the sentence is emotionally loaded. Is it a moral weakness to follow one's moral compass? I hear what you are saying, but you may want to consider that they do not want to make that decision, because their moral compass marks it as killing someone ( including some earthly jurisdictions ).

Maybe I misread the post above, but it sounds like no one would take her out of the hospital to die at home.

I agree that often times it is a matter of moral weakness. If the family knows what the wishes of the dying are, but are scared or unwilling to carry them out, that is a moral failing. I know many people who have gone through this, and the family often regrets their choices and weaknesses after the death. They wish that they could have been stronger and tell the doctors that they can stop treating the patient.

It is possible I misread it. If so, I would agree with your interpretation. There is a question of whether dying wish outweighs one's own moral compass ( and therefore is a moral failing ), but I accept your point especially if it is motivated by fear rather than consideration of one's principles ( I was never in that position, and hope I will never be, where I had to make that call ).

Sorry if I didn't describe it properly, english is not my native language. Giving of opium wouldn't anyhow shorten her lifespan, which was already on a fast spiral down with various organs shutting down, while causing huge amount of continuous pain, and there was nothing current medicine could do to fix it.

Her being in hospital vs being at home was just decision to not die surrounded by nurses and doctors but by family, which is completely understandable and I would opt for it too in same situation.

The fact that even closest folks refused to ease suffering while shielding themselves with at-best dubious christianity-based moral stance of easing/skipping purgatory is just beyond my comprehension.

And yes I truly consider it their moral weakness and failure. Its not about killing in any way, but sedating enough to have their last moments filled with sanity and focus on family, and not screams of huge pain.

> And more importantly, what if the dying person is ok with suffering?

Now this part is complete bullshit, of course she didn't want to suffer, she had brighter moments when she was begging for painkillers. I presume you were never in situation where you suffered huge amount of pain continuously for at least many hours. I experienced it once, and it completely utterly breaks you down mentally. You are willing to do basically anything to make it stop - there is a reason why it is/was used so much to get any intel, at one point everybody breaks, its so overwhelming that people make up anything to make it stop.

I hope its a bit more clear, it was a complex situation to describe fully in few sentences.

I have always considered some of that as practice for the eventual patient who may actually be helped. All those ecmo treatments on doomed elderly covid patients is good practice for when a 12yo kid with hope of survival needs the proceedure. Over the decades, hail mary treatments at end of life (radiation/chemo etc) eventually trickled down to become practical treatments for everyone. Appendectomies were likely debated as painful end-of-life treatments by those who first attempted them.

I know this an outlier, and not related to emotional hospice decisions, etc but my mother had a heart attack in her 60s and was flatlining after they were reviving from cooling? protocol at the hospital. The doctors used defribrillators multiple times while I and siblings were in the room. The head doctor turned to us with an annoyed tone saying "look this isn't ethical to continue" when we asked if they could do anything. He then agreed to give her an adrenaline? shot, then they packed up and everyone walked out to our confusion.

She stabilized and survived, and is still here 12 years later. I appreciate what the doctors did for her, but I am very cynical about blindly trusting what overworked/numb medical workers tell us now though.

> In some cases this is motivated by religious beliefs that "everything must be done" to save a life no matter how much pain or suffering is causes.

Can you explain what you mean by this?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6525567/

> Patients who rely heavily on their religious beliefs to cope with cancer have been shown to receive more aggressive interventions (e.g., cardiopulmonary resuscitation and ventilation) in the last week of life compared to those who rely less heavily on [Religion and spirituality] beliefs.

> The most commonly highly endorsed items (i.e., at least ‘somewhat’) were “my faith helps me to endure the suffering that comes with difficult medical treatments” (71%); “I will accept every possible medical treatment because my faith tells me to do everything I can to stay alive longer” (67%); and “I believe God could perform a miracle in curing me of cancer” (69%). Most patients (87%) reported some (‘somewhat’, ‘quite a bit’ or ‘a great deal’) endorsement of at least one of the RBEC items and a majority (62%) endorsed three or more RBEC items.

> Item-total correlations revealed high item-total correlations (>0.7) for five items and moderate correlations for the items “do not resuscitate orders are immoral due to religious beliefs” (0.48) and “I would be giving up on my faith if I stopped pursuing cancer treatment” (0.63).

Yeah, it’s very distressing. It seems that there is often a correlation between religious thinking and hoping for a miracle that defies reason.

You'd think they'd be pro-death and look forward to meeting them again in whatever afterlife they believe in. Or does faith falter in the face of the fragility of life?

No, I wouldn't assume the religious are "pro-death".

There's a correlation between being religious and being "pro-life". Even the dimmest pro-lifer can see that it's hypocritical to insist on saving the life of a foetus that has never seen daylight, at the risk of the mother, while allowing an old, sick person to die naturally. So they are forced into an "all lives matter" posture.

That’s hardly surprising, given the treatments of miracles in the Bible. If you believe in those, why think that no more miracles are forthcoming?

How much freedom do physicians have to refuse to provide treatment in such cases?

I know a lot of doctors and all of them have told me much the same.

who pays for these treatments?

>religious beliefs that "everything must be done" to save a life no matter how much pain or suffering is causes. It's morally distressing.

A life full of pain and suffering is still a life. The alternative you're offering is not something without paid and suffering, it's worse. Notexisting is worse than pain and suffering.

Except that death is fact of life, pain and suffering are not.

For some, the pain and suffering is so bad that notexisting is actually better.

> Notexisting is worse than pain and suffering.

That’s a stretch.

Far more important to come to terms with mortality than extend life indefinitely.

Is it even still living to have a heartbeat but with motor control, limited or no ability to speak, and no memory? Is “living” in this way best for the next of kin?

I found a recent episode of the Making Sense podcast in this topic to be thought provoking. You might give it a listen.

https://www.samharris.org/podcasts/making-sense-episodes/297...

I completely disagree. I would rather not exist than be in truly agonising pain for the rest of my existence.

Heck, I've had something as simple as bad food poisoning where, if it was a terminal symptom, I would have ended it.

You didn't exist until you were conceived. That wasn't so bad, was it?

A case I recall particularly vividly was a man in his late 90s who had end stage dementia to the point that he couldn’t interact with his environment or even speak. His limbs were contracted and he was permanently in a kind of fetal position. He was fed through a tube but was still severely malnourished. He had a line of bed sores starting from his coccyx extending up to his middle thoracic spine and most of the bones and ligaments could be clearly seen. The only real signs of life were moaning when he was turned in bed. I saw him in the icu where he was being treated for these incurable bed sores and bone infections. To me it was pure torture and his poor nurse was new to the job and broke down sobbing one day after she had to turn and clean his wounds. It was terrible for all of us.

I would never want anything other than comfort care for me or my family in that situation but the families religion dictated that we continue.

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