Role of Wrongful-Life Cases In Palliative Care

 

11SPAN-master768Earlier this week Paula Span wrote in the New York Times about the increasing number of lawsuits being filed on behalf of patients being kept alive. Counterintuitive? Not when you consider they were kept alive only to endure more pain and suffering – against their known wishes.

If you’ve ever read or heard about a court case involving whether, how, why or why not an individual’s advance directive was carried out as intended by the patient, then you are no doubt familiar with the myriad circumstances and events that can lead to great confusion at the time of death. It’s an area of healthcare painted with a thousand shades of grey.

Unfortunately, an advance directive often gets twisted and manipulated nine ways to Sunday in the hands of numerous stakeholders standing bedside, whilst the person in the bed is most often unable to advocate for their own interests. This is when doctors begin envying lawyers because lawyers don’t have to practice medicine.   

I have yet to meet the physician who wants to cause his or her patient harm. They even swear an oath not to. There are other areas of the Hippocratic Oath wherein its fulfillment brings into question – absent an informed directive – to just what lengths are necessary and appropriate to save the life of a dying soul in the knowledge that such actions may cause increased suffering.

Allowing for the presumption of innocence, however, doesn’t change the very real consequences suffered in those cases shared in the article. I suspect attributing the failures to a breakdown in communication is a safe bet in most of those cases since that is a phenomenon, which continues to plague our healthcare delivery system despite the investment of billions into information technology.

Of course, the broader discussion this story touches upon is addressing life and death in the context of quality of life – and who determines the subjective nature of “quality.” To that point, we have much to benefit from the continued awareness and education of the role palliative care can play in treating severe and terminal illnesses.

In this country we are culturally adamant about resisting and ignoring the realities of death. One needs look no further than the hysterical idiocy that surrounded death panels. Perhaps these cases will help advance the broader conversation we need to have on how we can best protect individual patient rights while providing them the best possible life while still on earth.

Cheers,
  ~ Sparky

The Business of Medicine

The primary reason I love what I do is that gaining competitive advantage (as in being able to stay in business and provide for a family) requires a commitment to continuous learning. If I could change one thing about myself after all these years it would be to increase my reading speed without sacrificing comprehension. I often get frustrated by not having enough time to learn everything I would like.

Sometimes learning isn’t so much about discovery as it is connecting the dots you’ve discovered previously. You are engendered to reconsider what once were disparate pieces of knowledge and see how they can be formed into new thinking. This was the case for me recently when I read a blog post of A Country Doctor MD contributing to the KevinMD.Com blog site.

The article, If a doctor isn’t face to face with a patient, is he still a doctor? explores the fundamentals of a physician’s business model in lieu of regulated fee for service payment methodology. It explores the often paradoxical relationship between between time and money in the practice of medicine. I found that the issues and challenges described resonated with me because I have to deal with the same business issues and challenges.

There are parallels between the practice of medicine and consulting. Both businesses’ core value proposition is individual knowledge, reasoning and the ability to collaborate with others to solve problems. The risks and consequences of getting the right solution in medicine are decidedly much greater – and this should be reflected in higher comparative compensation. But I don’t think that is universally true by a stretch, and here’s why.

As the leader of a small boutique consulting firm determining how to price and sell engagements is a constant challenge. You are always building on your knowledge, so that the next client gets the benefit of what you learned working with the client before (I don’t know this to be true, but I would imagine it’s a similar situation with physicians: it’s a practice). We are always wrestling with how to price services when the value proposition is a desired outcome while the measurement of cost is in units of time.

And you get more efficient as you practice, so that the relative work effort to produce solutions decreases as experience increases. But that doesn’t necessarily translate into higher income because you have to remain market competitive. Of course, ideally over time your hourly rate increases to reflect the increase in value provided: getting the right solutions faster. That is, in consulting at least.

I don’t want to belabor the nuances of professional services business models. I share these observations simply to make a point. In consulting, we have the luxury of pricing our work based upon what we think is in the best long-term financial interests of ourselves and our consulting practice. The physician who is forced to accept a payment schedule – whether from governmental agencies or private insurers – does not have that luxury.

With the recent release by CMS of the Provider Utilization and Payment data there have been reverberations in the media about physician income and the relative contribution of cost to our healthcare system. I am not advocating for less transparency even if, as I wrote last week, the data as it was released is quite misleading. All I am saying is that given the comparative amount of education required (time and cost), the stress level involved and the regulatory handcuffs applied, I wouldn’t want to trade. I think this is something that policymakers had better consider and understand very soon – because I can’t stand the site of blood, nor read fast enough.

Cheers,
  Sparky

Photograph: from thechart.blogs.cnn.com

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