• Health care from the heart

    I try not to waste your time and the following will take some, far more than just reading this post. But if you really want to deeply understand health care and its benefits and costs, this will be time worth spent.

    Sometimes you have to feel not just think about a thing to understand it fully. Maybe some people know that (or feel that) intuitively, but I’m not one of them. It took me years to get it. I’m still working on it. This wisdom applies to health care as much as anything else. Where the “rubber meets the road” or “at the sharp end” it’s as much or more about emotion as it is about intellect. Things are decided from the heart, not with the head.

    I attempted to express as much to one of my great e-mail correspondents, Brad Flansbaum, a hospitalist in New York, when he shared a link to his recent post on advanced directives for end-of-life care planning. It’s an incredibly important topic and his post opens the door to it by linking to many worthwhile papers and articles, some of which I’ve now read.

    But reading papers about it, as good as they are, is not really how I need to get into it fully. It’s too “in the head.” Contemplating death and health care near the end of life, or, to be honest, health care in general, takes more than reason, it takes feeling. Why? Because that’s ultimately how we (or most of us) will decide these matters.

    I don’t care what you think when you’re sitting in your office, in good health. I don’t care what you say when you’re writing a paper for publication or debating health reform. Tell me, or better, show me what you’re going to do when your loved one is under the knife, in the ICU, a resident in a nursing home. If you haven’t experienced it, lived it, felt it, you really don’t get it.

    I don’t either. Not directly. I’ve seen others very close to me go through such things. Trust me, they’re not reasoning. They’re feeling. That’s how things, even the very expensive things, in health care are decided, at least to the extent we participate in deciding them.

    I don’t give assignments (how could I?) but this is the closest to one I will suggest. Listen to the Finding Emilie segment of the most recent Radiolab episode. It’s about a young woman’s near death and recovery after being hit by a truck. More than that, it’s about how her family participated in charting that recovery. How she was nearly left for dead, nearly sent to the nursing home for life, but, miraculously, is recovering. It’s an amazing story, the feeling of which can only be conveyed with the full audio-magic that the Radiolab team excels at.

    After you listen, think about these questions:

    • What would you do if the story was your own?
    • Did Emilie receive too much health care? Not enough?
    • Did her doctors work hard enough? Did they make the right decisions?
    • If you were Emilie’s boyfriend or mother or doctor, would you have considered the cost of her care, how it was financed? If not, why not? If so, how would that have factored into your decision making?
    • If, ultimately, decisions most of us make in health are from the heart, how do we navigate the system rationally? Should we?
    • If you don’t think this is part of the crux of the health care cost issue, what is? Why do we love to spend so much? Are we thinking or feeling?

    I can’t think my way through end-of-life issues. That’s not because I can’t think. It’s because that’s not what it’s about. In health, and perhaps in all things, if one disconnects one’s head from one’s heart, one never gets the full picture. One is left wondering why some people behave so, well, irrationally. How can they make such decisions?

    The problem is not theirs, but ours. They’re not being irrational so much as just being human. Until we understand that we can’t understand anything.

    (Note: Here’s my response — Aaron)

    • Since I know that trauma care is effective and young people are very resilient my heart and brain would on the same side.

      IMO we should try to resist our heart and go with our brains but I know that is difficult especially at the point in time. IMO that is one reason why advanced directive are good. Just filling it out gets one to think through the possibilities. We make life and death decisions all the time i.g. driving is the most dangerous thing we do but we do it anyway.

      Another thing that can help us make decisions is that you can usual judge life years against life years. Expensive heroic procedures often make some people live quite a bit longer but on average in net cost life years.

      Now on another track, sometimes I think that it would better if people did not even know that they have a condition.

      Not easy questions. Very difficult. I have thought that perhaps if care was done by charities especially those funded by religions it would make decisions easier and more rational.

    • Thinking more about my last paragraph, I think that a lot of the struggle between democrats and republicans is the struggle between religion and the state. The death panel accusation is not to question of weather people should die or not but who should decide. Democrats would like government to rationally decide things and that has some benefit but religion lends conviction. Another advantage of religion is that though it is difficult to switch religion it is easier to switch religion than national government and that has benefit, For example If you are not convinced that the Baptist hospital system has the right level of care you could become a Methodist. It is more difficult to become a Canadian. (I do not think that Canada will take USA citizens that are poor and have no post secondary education.)

      These are basically religious decisions. We are willing to let people die all the time unnecessarily we just don’t want to be carry the blame/guilt. Religion allows to push the decisions off to some one else (God or the hierarchy). This has the benefit of allowing people not so emotionally envolved to make the decisions which is generally good.

    • ” Democrats would like government to rationally decide things and that has some benefit but religion lends conviction. ”

      That may be true for some Democrats, and I am officially an independent, but that is not what has been wanted by most Democrats I know. Certainly not those who have been pushing for end of life planning. What we want is for families and patients to talk this out to see what they want. We want them to understand their options. The only role we want for government is that it will pay for these discussions when they take place with a physician.

      I am probably too emotionally tied up with this since I see it so much at work, but I think the death panels claim is one of the sleaziest claims I have ever seen in politics. If Dante were writing now, I would hope he would add an extra layer of hell just for the people who pushed this line.