
Fighting to Honor a Father’s Last Wish: To Die at Home - kareemm
http://www.nytimes.com/2014/09/26/nyregion/family-fights-health-care-system-for-simple-request-to-die-at-home.html
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FireBeyond
As an EMT/Paramedic, the single best thing I’ve been able to do for patients
is take them home (or really, somewhere, ANYwhere other than a hospital or
nursing home) to die, in peace, in comfort, and with dignity.

We spend more to keep people alive, often in misery, in the last two years of
their lives than we often do in the two decades preceding it. Quality of life
doesn’t have an ICD9/10 code, though.

I’ve pushed back at doctors and nurses, similarly, who have discharged
patients to home, having blithely signed the form that “patient requires
transport in fully-equipped ALS (advanced life support) ambulance” (and the
bill that goes with it), when the patient is able to walk without assistance,
has no complaints or pain, and is generally and hemodynamically stable.

It’s obnoxious.

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skmurphy
It's to avoid "bounce back" charges and the risk of litigation. I am not
disputing your point that it's obnoxious but it's a risk avoidance behavior
that the hospital does not have to pay for.

~~~
FireBeyond
There's reasonable risk mitigation and there's unreasonable.

Cabulance. Even a BLS ambulance for sicker patients.

But an ALS ambulance (and the resulting bill between $2-3000), with
ventilators, cardiac drugs, etc., for a patient who is comfortable as
described, and has no history of respiratory or cardiac issues goes beyond
overkill.

The actual form has lines as follows: "Bed confinement defines the patient as
being (1) unable to get out of bed without assistance; AND (2) unable to
ambulate; AND (3) unable to sit in a chair or wheelchair", "condition must be
of sufficient severity that going by means other than this would be hazardous
to the patient's health or wellbeing" (and I'd argue that other than for end-
of-life care or similar, if you require an ALS transport to go home, perhaps
you're too sick to be going home).

That really crosses the line of reasonability to borderline fraud.

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JshWright
Makes me glad I just run 911...

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FireBeyond
Pretty much. We are dual service, 911 and IFT. I don't mind the IFT side of
things from the patient management experience, especially with chronic
patients, but yes.

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fubu
"Home care agencies abruptly dropped or refused high-needs cases like her
father’s as unprofitable"

This story is really, really glossing over what is happening in home health
hospice as a whole. For profit hospice organizations are crippling the non
profit organizations by taking all the cheap and easy patients offering them
slightly better services than the non profits, while dumping all the expensive
and unprofitable patients on the non profits who typically try to take every
patient regardless of their ability to pay, regardless of Medicaid and
Medicare. These non profits are being killed off one by one because of it.

Yet another example of finance style arbitrage damaging the lives of
Americans.

~~~
jnbiche
This is why the bastardized system we have now will never work. We must move
to single-payer or fully private health care -- no middle ground.

I personally don't even care all that much which route we take, since I think
the improvement in either case would be extreme. Unfortunately, both are
equally unlikely, because of two-party "democracy".

But the status quo is unsustainable.

~~~
refurb
Why must it be single payer or fully private? Plenty of countries with well
functioning healthcare systems have a mix.

~~~
jnbiche
Because in the absence of a single-payer system, the private portion of this
system risk arbitrates all the higher-risk patients to the state-supported
insurance and/or medical care, thus bankrupting the government and/or non-
profit systems. We see this happen again and again.

What countries with well-functioning healthcare systems don't have a base-
layer single risk pool under a government system? Of course, almost all of
these systems allow supplemental and/or optional private care, but they are
still single-payer insurance systems.

~~~
vinceguidry
Isn't that the whole point of the state from a market economy standpoint? To
take care of the things that are unprofitable with compulsion/taxation? You
can't bankrupt the government. It's got the power to print money. It can keep
going as long as it can do so. It also has the power of legislation. It can
regulate prices if it so chooses.

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comrh
My mother is a hospice nurse and it has given me a viewpoint I don't think I
would have ever considered before. Americans (and probably most people) seem
to ignore end of life decisions because it is scary, and it can be, but it is
important. So incredibly important, to the person leaving this earth to be
respected and to the people they leave behind to not have awful experiences
like this.

It seems to be changing a little, slowly, but as this article seems to
demonstrate there will be a huge amount of push back from a for profit
industry. And once you die the checks stop so I don't see an incentive for
them to do better.

~~~
jianshen
I would add that it's not just end-of-life decisions that we ignore or fear
but anything long term or non-acute. Modern medicine is geared towards getting
better quickly but there are certain ailments, be it old age, a traumatic
brain injury or mental illness, that we're absolutely terrible at dealing
with. It's not that people are not willing to put in the years (as is
demonstrated by the brave woman in this article) but that the learnings and
breakthroughs for long term illnesses takes generations, not years and sadly
we're barely at the starting line.

Please thank your mother for everything that she does for her patients and
thank you for sharing.

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tn13
Many of American healthcare problems will dissolve if US government allowed
Indian doctors to come to US and start practice on a cap free H1B.

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rcarrigan87
My brother worked as a sales rep for over 10 years in home health and hospice.
He has told me many war stories. Per the article, a lot of companies avoid
patients who are short-term (less than a week to live) because the companies
stand to lose money. He refused to do this and would regularly take on
patients that represented a $10-15K loss.

By doing so he formed close bonds with doctors and discharge planners who
would turn to him when no one else was willing to take a patient. These
relationships led to a lot of referrals and he grew his territory to one of
the strongest.

The company was later bought and new management enforced much harsher
oversight on patient profitability metrics. Needless to say, he quit.
Certainly something needs to change.

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ggchappell
I see that there is a problem here, but the article seems unduly vague about
what it actually is. Could someone explain?

What I mean: This man wanted to go home. For some reason, he could not. Was it
because he was _physically prevented_ from going home? Was it because, if he
went home, insurance and/or govt. assistance would be made unavailable, and so
with the policies that were in place, he _could not afford_ to go home? Or was
it something else?

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jnbiche
The problem was, insurance was happy to pay $500/a day for nursing home care,
but balked at paying anything near that much for home nursing, which he needed
to stay at home (since his daughter was a full-time teacher and also probably
couldn't lift him, etc).

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yason
If the money is owned by the same organisation that gets to spend it, the
money is spent wisely. If it costs one fifth to arrange for a daily care at
home versus at a nursing home, then that's four fifths saved for something
else in the total bill. However, if the one who gets to pay and the one who
gets to spend are different parties then both try to optimise from their own
perspective and generally end up with contradicting goals.

