Bankrupting the Medicare System – End of Life Issues

Medicare“R.D.” is 95 years old. She is frail, somewhat confused and remains in atrial fibrillation as her primary heart rhythm.  Atrial Fibrillation predisposes the patient to embolic strokes so the patient has been on anticoagulants or blood thinners for years to prevent these strokes.  Her unsteady gait and frail state have resulted in numerous falls. With each fall she bangs her legs and develops an accumulation of blood under the skin and in the soft tissues known as a hematoma. These are compressed, surgically drained and nursed to health with the help of wound care physicians and nurses who treat the patient at their office and at the patient’s home.  The process of healing is painful and takes weeks to months.  Just when we believe we have one wound under control the patient falls again and we start over. The patient is affluent and lives in her own large beautifully furnished apartment with the assistance of long term fulltime aides who care for her as if she was their own mother. Her children and grandchildren supervise the care and honor and respect their elder matriarch with the love and tenderness this sweet woman deserves.  We have discussed stopping the anticoagulant because the risk of severe injury from post-traumatic bleeding is now higher than the risk of a stroke if she is off the blood thinner. The family is fearful of a stroke robbing her of whatever existing independence and function she possesses and has declined that option repeatedly.

R.D. has a living will and has executed a “Do Not Resuscitate” form. Her home has been safety evaluated and adapted to limit or prevent falls.  Home oxygen has been supplied to keep her oxygen carrying capacity at a comfortable level. 

Due to her frail nature she fell again on her way to bathroom. She didn’t call her aide to assist her to the bathroom but the aide heard the fall.  The aide’s first instinct was to call 911.  The paramedics arrived and recommended transfer to the ER.  Despite a DNR form, a request for non-heroic actions and ongoing care by a team of physicians and nurses the patient ended up in an acute care hospital ER. A CT of the brain showed no cerebral bleeding. Her wounds were cleaned and antibiotics started. After 48 hours in the hospital she was ready to go home.  A friend of the family suggested a consult with Hospice. The full time aide wondered why they needed hospice. The children wanted “no stone left unturned” in providing care.

I happened to be out of town while the request for a hospice consult was made by the family. It was made to a physician who knows the patient and was covering the practice in my absence. He questioned what role hospice would play that the current caregivers were not already providing.  By the time I became aware of the request, the back and forth discussions had unfortunately turned contentious.  He and I, in my absence, were fired as care providers and hospice took over. Sedating medication was prescribed by the hospice medical director.  The patient expired from medication related issues before my return to town within 48 hours. She was essentially legally euthanized. 

In our community there are four hospice services. They are all for-profit making businesses. They do an outstanding job of relieving pain and providing comfort for dying patients and providing respite and comfort to family members. One of the agencies is known to be more aggressive with medicine than the others and when they are called in the patient sometimes expires quickly and much sooner than expected.  Since changing from volunteer agencies with no Medicare funding to for-profit institutions with Medicare and insurance coverage the hospice services have lost much of the warm personal touch.

This patient had excellent at home care and coverage.  End of life issues had been reviewed with the patient and family in advance of her decline. Despite this, changes are routinely made to the care plan as the patient’s health declines. The cost of these changes is billed to Medicare and we all pay for it. Patients who requested to be kept at home are transported to hospitals. Patients who have a complete and competent care team have well-meaning but desperate family members change the plan. It happens regularly and the services requested are often no more compassionate or comprehensive than the original plan and services but they are billed to, and paid for, by Medicare.  As long as the patient and family are not responsible for the bill the services will be provided whether they are truly needed or not even if the services are already available and being paid for privately by non-Medicare sources.

Increasing Dietary Fiber Decreases Your Stroke Risk

Fruits and vegetables v2Diane Threapleton, MSC, of the University of Leeds, England, and colleagues reported in the online version of Stroke that eating more dietary fiber may modestly reduce your chances of having a stroke. Additional grams of dietary fiber intake was associated with a 7% lower risk of hemorrhagic or ischemic stroke.  She said a 7 gram per day increase in fiber is easy to achieve being the equivalent of two servings of fruit like apples or oranges or an extra serving of beans.

United States guidelines call for the average man to consume 30 – 38 grams of fiber per day while the average women should consume 21-25 grams.  We fall far short of that with the average male consuming only 17 grams of fiber per day and the average woman only 13 grams.

Researchers note that soluble types of fiber form gels in the stomach and bowels, slowing the rate of absorption of foods and slowing gastric emptying. This slowed emptying increases our feelings of being full so we consume less food. They additionally noted “bacterial fermentation of resistant starch and soluble fibers in the large intestine producing short chain fatty acids which inhibit cholesterol synthesis by the liver and lowering serum levels.”

Once again, nutritional common sense prevails. Eating healthy, including more fresh fruits, vegetables and whole grain products results in more fiber ingested and fewer health issues occurring.

Medicare Will Never Be Able to Reduce the Cost of Care in the Last Three Months of Life

MedicareWe are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning.  Living Wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. I will provide some examples in the next few blogs.  Patient “L.J.” is my first example.

 I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.  Three years ago he went into a severe depression after losing his second wife, to dementia.  His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs.  He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.

In recent months he has refused to be transported to an infusion center for his transfusions.  Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to.   His nurse has become exceptionally attached to him.  As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.

Three months ago she suggested a palliative care consult.  I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs?  The children had demanded the palliative care consult so one was called. 

The local hospice program has a new palliative care program. They bill Medicare Part B for their services.  The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services. 

Three months later the same nurse contacted the family and said the patient needs Hospice care. I asked “why”?  She told me her mother had died of cancer and Hospice had been very helpful. I have no objections to working with Hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point.  When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for Hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.

It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care.   The taxpayers’ foot the bill as the system fails from expenses it cannot meet.

 

Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs