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HEALTH CARE: Obama's Grandmother and the National Conversation
President Obama speaks about his grandmother's death and the questions it raises about end of life care in an interview published in this weekend's New York Times Magazine. It's a thoughtful and frank public airing of a painful topic. The Times' Peter Baker wrote a related article linking the president's comments to the politics of health reform. The questions Baker raises about scarce resources and decision-making were perfectly legitimate, given the political moment we are in, but they aren't the questions that came to my mind as I read the piece. (On the web, the relevant portion of the magazine interview starts at the end of page 4).
The questions I wonder about were why, exactly, did Madelyn Dunham (Obama's grandmother) get hip replacement surgery given that she was suffering from heart disease, terminal cancer and possibly had had a stroke. I'm not talking about the cost, here. I'm talking about whether it was really the best option for her, or whether she was a victim of our procedure-driven "let's do it because we can" medicine. Did she fully understand the risks and implications, not just while she was in surgery but during the recovery? How well did anyone explain other less invasive options? Who—if anyone—was coordinating her care? Were the various specialists (that may have included oncologist, surgeon, cardiologist, orthopedist, hospitalist and/or internist and who knows who else) communicating and how? Was a pain or palliative care specialist consulted?
And above all, was the care she got in keeping with her end of life goals and her personal values? Because if there's one thing the 86-year-old grandmother probably wanted after learning during the campaign that she had terminal cancer was to live long enough to see Barack Obama give that historic victory speech in Chicago on election night—and maybe, if she was lucky, to live long enough to watch him take the oath of office when he became President of the United States. As we all recall, she died less than two days before his victory. We all watched that tear slip down his cheek. The timing made even many of his political opponents grieve for him.
"I don't know how much that hip replacement cost," Mr. Obama said in the interview with David Leonhardt of The Times. "I would have paid out of pocket for that hip replacement, just because she's my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model is a very difficult question."
He went on to say: "If somebody told me that my grandmother couldn't have a hip replacement and she had to lie there in misery in the waning days of her life, that would be pretty upsetting."
That's the tragedy. The money was spent. The operation was performed. But it neither extended her life nor enhanced the quality of her life. She began to fail. In about two weeks, she was dead. She lived long enough to cast her absentee ballot. But not to long enough to see it counted.
Obama doesn't want to take the power to make those decisions away from patients and families, to"micromanage the doctor-patient relationship." But he wants better guidance, for our federal health care dollars, and for families facing these hard decisions on their own.
"There is going to have to be a conversation that is guided by doctors, scientists, ethicists," Mr. Obama said. "And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance."
But I think about the other conversations, the conversations that Dunham had after she fell and broke her hip. The doctors said she had three, maybe six, maybe nine months left because of the cancer. The hip replacement surgery carried risk, because she also had heart problems, but the doctors apparently painted a miserable picture of life without the surgery.
Did they explore—adequately—nonsurgical alternatives? I don't know how severe her fracture was, how at risk she was for greater injury, what nonsurgical alternatives were even available to her. (Approaches like traction, I've read, can have risks of their own in some cases if frail elderly patients need to be immobilized). I'm not a doctor so I don't know the clinical answers to this (although I'll email this post to some palliative care experts and geriatricians I know and invite their comments). But I do know that we have ample data showing that expensive interventions at the end of life do not necessarily produce better outcomes. Had Dunham opted to live out her days without the risky surgery or was being "miserable" her only option? Could her pain be controlled? Would she have any mobility? Would living with the injury, for however long she had left, have been better than the pain and trauma of surgery? Research has shown that given a full accounting of all the pros and cons of all the options, patients often opt for the less aggressive, the less interventionist treatment.
Obama's right. These aren't decisions to be made in the course of "normal political channels." But we need both the national conversation that Obama envisioned, and another kind of conversation, a conversation that puts the patient at the center. Surgeons who are invested (emotionally invested, intellectually invested, habitually invested, not just financially invested) in surgery may give the patient and the family a very different perspective than a palliative care physician, or a geriatrician or a family practitioner. But our health care system, today, places a higher value on that surgeon doing his surgery, than those other physicians trying to work through what the patient wants. Patients need data and evidence. They also need wisdom and compassion. Cold-clear facts delivered straight from the heart.
Excellent
I can't say enough about this article.
As someone who deals with these issues on a daily basis as an intensive care physician and someone who has been teaching physicians about end of life care for many years, I commend you on your insights into the issues.
The only thing I would add is that physicians are, in the vast majority, uncomfortable with dealing with these issues. Therefore, it is often easier to just proceed with the procedure or more chemo or an implantable defibrillator or intensive care unit admission and life support and on and on. It requires significantly less investment to keep pressing on, and that includes both time and emotional investment.
Good Questions
I also read the article to which you refer and my questions after reading it were similar. I got the sense that the palliative care option hadn't been been broached and I wondered why. Thank you for writing about this.
reaction to article
Thank you for your astute comments. I had a similar reaction after hearing the president speak movingly of his grandmother's plight. It's unfortunate that he seemed to be under the impression that surgery was her only viable, albeit expensive, option. I am not a physician either, but I am a medical journalist and author who has written an End-of Life Matters booklet (www.whitecoatwisdom.com) that explores some of these issues. The bottom line is that doctors and patients do not know when to call it quits. Death is part of the life cycle and to pretend that we can hold it off indefinitely is rather sad. We all need to confront the painful realities and recognize that we can't afford to do everything medically, especially when it won't be effective anyway. The positive side is that comfort care really is the better option. Two years ago, my father passed away at age 88 with all of his loving family with him. He had extensive heart disease and organ failure, so we followed his wishes and made sure he was comfortable. He slowly and painlessly slipped away. He never could have survived surgery and it would have been an expensive, foolish option to take, even if there had been a surgeon willing to try. My dad lived a good life and had a good death. We all should be so fortunate.
article on health care
you are completely missing the point. obama wants to have government officials decide who gets hip surgery and when. he preaches sacrifice for others, for the common good, but never pactices it with himself or his family. the point is that he claims he would have paid for his grandmothers surgery himself, but he didn't. just like he said he wished he had served in the military, but he didn't. he is so sympathetic to the economic woes of the struggling masses, yet he waists incomprehensible amounts of public money to take his wife on a date to a play in new york. he supports cap and trade/tax that will massively increase energy costs on the average citizen so that the government can regulate CO2 emmisions - do you breath when you think - you emmit CO2. this is not CO which is poisinous, this is CO2, its called respiration. we breath in oxygen and out comes carbon dioxide, CO2. guess what! plant love it, they thrive on CO2. they take CO2 and give of oxygen - what a beautiful planet. i understand he is charismatic and an eloquent speaker, but for GOD's sake listen to what he is saying and compare it to what he is doing.
health care needs to be rationed, the country is bankrupt. who do you want to make your health care decisions, you or obama! i am afraid to many will choose the latter and we will all regret it in the long run.
Hip fractures hurt a
Hip fractures hurt a tremendous amount. It is cruel not to do something about them. If the plan is to put down (someone else's) grandma, let's be upfront about it. About the only time a hip isn't fixed is when a patient is near death or has such a neurologic condition they don't move or have much pain.
And it's half a hip replacement, not a total hip replacement.
Takes 1/2 hour and gives good pain relief.
I'm a doctor who is a DNR, but fix my hip to relieve my pain, not a cyanide capsule.
We need a real discussion about health care, not lies about how no care will be denied, no choices taken away and no hard choices.
It's not a Trojan horse, really...
Author: "Obama doesn't want to take the power to make those decisions away from patients and families, to"micromanage the doctor-patient relationship."
Author quoting Obama: "There is going to have to be a conversation that is guided by doctors, scientists, ethicists," Mr. Obama said. "And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through normal political channels. And that's part of why you have to have some independent group that can give you guidance. It's not determinative, but I think has to be able to give you some guidance."
If the family is making the decision, what need have we for a "conversation ... guided by doctors, scientists, ethicists..." or some "difficult democratic conversation?" If Obama indeed "doesn't want to take the power to make those decisions away from patients and families," then we're better off leaving the decision - in it's entirety - with the patients and their families. Despite the empty rhetoric, this health care proposal does precisely what the author of this article assures readers will not happen. With this proposal, health care decisions will be made by committee; for the "greater good" of the whole.
Is Obama suggesting someone should have intervened and not allowed his grandmother to receive the hip replacement? Is is really a "tragedy" that his family were able to make that decisions? Can we trust families and doctors to make good decisions?
Whether we can trust them to do so or not is frankly, irrelevant. The fact is our society is set up to allow personal choice - it allows each individual free agency to make their own decisions. Is the debate now to end this core value of society? To take away the agency to make medical decisions, putting them instead in the hands of committees? May we deny the real debate no longer! Let's argue this for what it is - an unprecedented, huge expansion of government. This IS a push for socialized medicine. Treatment covered by taxes; decisions made by committee.
Give me liberty or give me death! Even if I make the wrong decisions regarding my, or my loved one's care, the decision is mine, not some committee. Whether Obama acknowledges it or not, this plan DOES remove that decision from the hands of the individual or family, ultimately putting it in the hands of politicians and doctors (an observation of truth is not "dissinformation," FYI). Maintain the liberty to make your own decisions about your and your families care. Say no to this socialized health care Trojan horse!
Health Care Reform
I read your piece on "Obama's Grandmother and the National Conversation." Broken hips must be repairedfor two reasons:1)the pain experienced by the patient can be tremendous. 2)the patient is immobilized until the hip is repaired. Immobilization can very easily lead to pneumonia in 40 year olds who smoke let alone 86 year olds with heart disease. I see some posts speaking of the "palliative" option and doctors who are uncomfortable talking about "End of life" issues. There is no "paliative" option unless she isn't your Grandmother and you don't care about her pain level, and the 3 to 9 months she could have lived longer. Hopefully, you and your ilk will not be on one of these arrogant panels, because the "end of life" to you is someone with terminal cancer, 3-9 months to live and a broken hip. You would place this women in the bed with traction, reduce her pain by sedating her with narcotics which would only hasten the onset of pneumonia (lungs are used less) which in turn would bring about her demise. Congratulations, you've just saved the brave new world 30 to 40 thousand dollars by killing this women in a couple of weeks when she could have possibly lived for 3-9 months. You arrogant people are all the same until it's you or yours in the bed facing pain and death, then you want every thing done. I've got an idea. Why don't you, Obama, and the rest of the Political class give the tax payers money back, stay the hell out of the free market, and let people pay for and negotiate their own particular method of leaving this life in a way that is comfortable for them, not you or some self serving panel. Who made you, and that imposter for a President God? The reason Healthcare is an issue is liberals think they know what's best for other people. They are always comparing themselves, groups, to others, and then with their infinite wisdom concluding what is fair. What is fair is for you, and people like you ( self centered Marxist ideologues ) to stay the hell out of peoples lives. I'm a 15 year Registered Nurse who has worked in all the various Intensive Care Units and Emergency Departments. Each patient has different needs and beliefs. Many even after extensive explaination choose hope of more life. That is an extremely personal decision that is made by the patient in accordance with that patients beliefs. You and I are not invited into that realm. We are not facing death as they are. It is between them and who they perceive as their maker. If you want to help, leave them alone.
surgeons only care about doing more procedures
As a hand surgeon, I am sick of hearing the "President" bashing specialists and elevating the family doc...There is a real misconception that only primary care doctors sit a spend time with their patients...Do you know I have to answer about a thousand questions before taking a splinter out of someone's hand?!Do you know I have about three times the training of your typical primary care doctor. I regularly have to immerse myself in HIV infected blood, risking infection and death to myself and my family, for not one cent of additional pay due to this risk. I risk financial ruin with every new patient contact- available for a pot shot from any patient that wants to file a nuisance lawsuit against me to try their hand at winning the "lottery". My patients stick their hands in meat grinders, and want to know why they don't have "full function" after treatment!!. Tell ya what, next time your kid blows half his hand off playing with firecrackers on Saturday afternoon...do me a favor--don't call me...I'll be busy enjoying my time off with my family at the pool---call your primary care doctor,so he can discuss the benefits of lipitor vs crestor! It already is almost impossible to get a specialist to actually come to the ER---the paultry pay we get now is simply not worth the loss of family time, malpractice liability, and potential exposure to infectious diseases ( don't even begin to mention the Hippocratic oath to me as a defense). Will slashing my fees any more make me or any other specialist more available to take care of you or your loved one in a crisis situation?? Next time you have a flood and the plumber says his fee is $300....offer him $40 and see how fast he comes running to take care of you....Remember, a flood is bad, but 3 fingers in a bucket waiting for some miracle reattachment is a whole different animal.....God save America from the "Pied Piper" in the White House