Too old for life saving treatment?
Earlier this year, a pair of influential bioethicists argued in an essay in The New Republic that the amount of money the country spends on Medicare is unsustainable. With senior citizens the fastest-growing age group in the country, they say, the only way to control the ballooning costs is to try to bring the entire population up to a life expectancy of 80 and stop using most expensive technologies and medicines to extend life beyond that, even if some people will die.
This article was published by the Chicago Tribune on November 30th 2011. To see this story and to read related stories on the Chicago Tribune website, please click here.
Aging out of health care?
By Lisa Pevtzow, Special to the Tribune
November 30, 2011
More than 11 years ago, at age 89, Mary Cipolla, of Roselle, went through surgery for a rare type of pancreatic cancer, a “Hail Mary” procedure that removed parts of her stomach, pancreas, bile duct, gallbladder and small intestine — and saved her life.
Now 101, Cipolla is one of a rapidly increasing number of senior citizens whose lives have been lengthened and made healthier by medical advances in ways unimaginable even a generation ago. Centenarians undergo angioplasties and receive heart stents for clogged arteries. People in their 90s routinely have hip replacements. For these and many other procedures, there is no upper age limit.
The extra years Cipolla was given have been infinitely precious to her family, said her 84-year-old sister, Jean Pipilo, with whom she lives. But as health care costs continue to rise, some experts have opened a discussion about whether the nation can afford these miracles of modern medicine.
Earlier this year, a pair of influential bioethicists argued in an essay in The New Republic that the amount of money the country spends on Medicare is unsustainable. With senior citizens the fastest-growing age group in the country, they say, the only way to control the ballooning costs is to try to bring the entire population up to a life expectancy of 80 and stop using most expensive technologies and medicines to extend life beyond that, even if some people will die.
The Medicare program — unlike health plans in other countries — is not permitted to factor in the price of medical services, only the health benefit to the patient. No proposal is being discussed to change that. But Sherwin Nuland and Daniel Callahan believe there should be.
“If you want to save all lives, you’re in trouble,” said Callahan, co-founder of The Hastings Center, a bioethics research institute in New York, and a faculty member at Harvard Medical School, in an interview. “And if you want to save all lives at any cost, you’re really in trouble.”
Callahan and co-author Nuland, a retired professor of surgery at Yale School of Medicine who wrote the best-selling “How We Die,” were both 80 when the article was published.
“We need to stop thinking of medicine as an all-out war against death, because death always wins,” said Callahan.
About 45 million people 65 and older are covered by Medicare, the only age group that has near universal health care. This costs taxpayers nearly $491 billion per year, an amount that is projected to increase to $776 billion by 2020, according to the federal Congressional Budget Office. At that time, Medicare will make up 14 percent of the federal budget, it estimates. (Defense spending, in contrast, is expected to comprise 16 percent.)
Medicare was signed into law in 1965, a time when life expectancy was 67 for men and 73 for women, and half of people 65 and older had no health insurance. In 2007, life expectancy had grown to 75 for men and 80 for women, according to the U.S. Centers for Disease Control and Prevention. In contrast, in 1900, life expectancy was 46 and 48, respectively.
No one wants to die, Callahan acknowledged, but people have come to expect that their lives will be prolonged by modern medicine regardless of the cost, and doctors try to cure patients who are beyond any hope of a cure. A recent study in The Lancet shows that nearly one-third of Medicare patients in 2008 underwent surgery in the year before they died, and about one-tenth in the week preceding death.
“Doctors can keep you alive until you are 105, but that may not be a particularly good aim of the health care system,” Callahan said. Senior citizens should receive good basic health care, but the main resources should go to children and the adult population, he believes.
“And that upsets an awful lot of people,” he acknowledged.
Four years ago, Loyola University Health System cardiologist Ferdinand Leya performed a balloon angioplasty on a 96-year-old South Side woman. The patient recently celebrated her 100th birthday. Last year, a woman received a new heart valve at Northwestern University Hospital. She is now 102.
Not every senior can be helped with surgery, Leya said. Many are too sick and there are those, such as people with Alzheimer’s or who are on ventilators, whose quality of life would not be improved. Physicians should use the vast amount of research data available to figure out who can be helped. But even among the oldest, he said, there are people who can be helped as much as patients who are in their 50s and 60s — and he believes it would be immoral to deny them care.
“These people are full of life,” Leya said. “They have grandchildren to take care of and family to love. They would do anything to stay healthy and, as long as their quality of life is improved, we should do anything to help them.
“Who are we to cause the death of a patient?” he asked.
For June McKoy, a Northwestern Memorial Hospital geriatric specialist and researcher who sits on the hospital’s ethics committee, the consideration of cost must come second. “If you think of the cost first, you wouldn’t take care of most patients,” McKoy said. “The cost can be mind-boggling.”
The cost of Cipolla’s surgery was about $50,000, according to her surgeon, Gerard Aranha at Loyola. A reasonable price for a coronary bypass surgery in the Chicago area is about $57,000, according to the Healthcare Blue Book, and a hip replacement can cost $20,500.
That said, McKoy believes doctors have a responsibility to spend medical resources where they do the greatest good. They must police themselves — otherwise, the government will come in and do it for them, she warns.
This is not easy, she said, describing the tremendous pressure doctors are under to perform procedures and prescribe medicine that will not help. And, she said, they often give in.
“We get selfish families, and it’s often easier for doctors to pull out prescription pads,” she said. “Doctors need more often to say no, to say (if a patient is dying): ‘We will give you palliative care, but not give you chemotherapy. We will not give you new expensive drugs because it will not make you better.'”
Likewise, medical schools also need to train students to understand the cost-effectiveness of treatments, and to administer them based on medical research into their effectiveness — not just because they are available.
“We have to have doctors willing, in a compassionate way, to tell the hard truth,” she said. “I tell families, ‘Your relative will die and there’s nothing we can do about it.'”
Yet, often surgery is warranted and ultimately proves less expensive, she said. Spending $100,000 to fix the heart of a functionally active 90-year-old, for instance, is a one-time expense that can cost less in the long run than nursing home care and repeated doctors and emergency room visits, which Medicare also covers, she said.
“I want to make people well, if I can make people well,” McKoy said. “We don’t have to ration Medicare on the backs of seniors who have built up this country.”
Hymen Milgrom went to his doctor complaining of shortness of breath, chest pains and dizziness when he was 91. He had undergone a heart bypass operation in his 80s, and had moderate to severe heart failure, with blocked arteries and a faulty cardiac electrical system, said Leya, his doctor. First, Leya gave him a pacemaker. That didn’t help. Then, Leya used a tiny rotating blade at the end of a catheter to reopen the blockages and put in stents to keep them open.
Milgrom, who lived in the Budlong Woods neighborhood of Chicago, died earlier this month at 97. He had said recently that in the years after his procedures, he was able to garden and to travel regularly to Israel to visit his son and to New York to see his daughter, grandchildren and great-grandchildren.
“We need to make the (Medicare) system more affordable,” he said, “not more unavailable.”
