“Throw grandma under the bus” clearly conveys anger, sympathy, and fear when health care decisions are made outside the realm of medical professionals. Within the doctor-patient relationship, alignment of physician expertise with an individual’s personal decision should keep insurance company executives, hospital CEOs, and government authorities from interfering.
Are we naive to believe interference isn’t already occurring?
A doctor orders a breast MRI to further evaluate an abnormal mammogram, but the insurance company denies approval. Physical therapy after a broken hip must be done at a facility sixty miles away instead of down the street because “we don’t have a contract with them.” The physician recommended evidence-based cancer surgery cannot be initiated as it is not authorized by the insurance company. A mid-nineties woman is told she must go to a nursing home because her “double” pneumonia is beyond the four days allotted to the hospital for her care. Yes, we’re already throwing grandma under the bus.
The health care role of doctors is to heal, and for some extends to end-of-life care assuring minimal pain and maximum comfort in your final days. Somehow though, unscrupulous profiteers have found ways to covertly intervene claiming patient benefit, when their real purpose is profit. Therefore, I wish to forewarn and expose to caregivers and health care professionals new threats against those we care for.
As an internist and hospice physician, I was asked to see a patient with a “terminal disease” for end-of-life comfort care. She lived with her family on a ranch outside our town, and when I arrived, she was actively sweeping their front porch with no signs of debility or pain. Being able to access her hospital chart, I found the HMO had not done the usual workup nor staging of her cancer. As Medicare funding is separate, by placing her on hospice the HMO was able to financially “wash their hands of the patient” saving money by not providing any further care. I reported them to a state agency, and advised the family of the problem resulting in appropriate care and treatment.
In the hospital setting, I now see aggressive questioning of families and older patients seeking code status change to DNR (do not resuscitate), coercing them to a lower level of care. Coupled with this sometimes is an attempt to place them on hospice. Under certain circumstances I cannot disagree, but wouldn’t you expect those asking these questions be physicians? Unfortunately, they are not. Sometimes they are nurses, social workers, and even case managers maneuvering under the guise of “palliative care team.”
Furthermore, part of this stratagem is oversight of the palliative care team is by an administrative hospital committee which formulates policy away from the scrutiny of physicians. Orders are placed by non-physicians asking for palliative care personnel to consult patients which in not only illegal, but practicing medicine without a license.
Far before hospitalization, I discuss with my elder senior patients their sense of quality of life and expectations of how aggressive they want to be treated at end-of-life. No one lives forever, and everyone uniquely makes decisions based on personal relations, family, religion, experience, common sense and reality.
But hospitals abide by Medicare rules of payment and might lose money when a patient stays too long. Therefore, reducing care by forcing code status changes of patients under duress is inappropriate especially when it is not presented by the physician. A new twist in this problem is at some hospitals, physician care is turned over to a hospitalist, who has never met the patient nor family. If these hospitalists are paid directly or indirectly by the hospital, you already know the tenor of their questioning.
Not to be misunderstood, there are many caring physicians, including hospitalists and palliative care teams, focusing on the best interest of the patient. Again, sadly, who pays them determines the fate of many of our elder seniors.
The present medical system is too vast and complex for most to understand or read between the lines. Being aware of the above unseemly profit-making tactics might help you and your loved one ask questions and make better choices. Personal decisions should not be twisted or coerced by insurance company executives, hospital CEOs, or HMO profiteers, and ultimately we must demand to uphold the sacred relationship between doctor and patient.
Throwing grandma under the bus should not be an option.
Gene Uzawa Dorio is an internal medicine physician.
