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PT and the Greater Good

When Do We Say ‘Enough'?

Published October 25, 2011 2:25 PM by Dean Metz

I'm tired of smelling like an ashtray. I work two days a week on our chest service providing chest physio to patients with COPD and/or bronchiectasis. Many of them are "frequent flyers" and most of them are still smoking. Sometimes I wonder why we continue to treat them? They take no action to help themselves and use up valuable resources that could be put to use on people motivated to get well and stay well.

One of the common themes in health care reform is prevention and health promotion. Well that's great, but what if nobody wants to listen? Would the threat of discontinuation of care be enough to get people to change behaviors? I know that isn't considered ethical, but is it ethical for people to ignore medical advice and continue to demand care?

Since the advent of improved sanitation and antibiotics, the major killers these days are chronic conditions: COPD, heart disease, diabetes and others. Most of which are "lifestyle" illnesses. Medicine is now better than ever at prolonging life with these conditions, which also increases the costs for treating them. Fellow ADVANCE blogger Dr. Patt wrote several months ago about all the "future strokes" she saw when in a public setting, referring to the supersized people. These chronic conditions are rapidly depleting the resources of the NHS, Medicare and Medicaid as well as driving private insurer premiums up. We all pay the price for the extended life span of the chronically ill.

At what point do we say, "No more"? "You've put yourself in this position and it is not our responsibility to get you out of it." Where do we draw the line; after the first heart attack or COPD exacerbation? After somebody's BMI goes above a certain number? What about the people who get into a car wreck because they were driving on worn tires? Should we not treat them because it was "their fault"?

With health care reform taking place on both sides of the pond, there are a ton of ethical considerations to think about. In the meantime, I will go twice a week to homes with tar and nicotine dripping down the yellowed walls and try to educate the unwilling.

4 comments

Great discussion.  It is indeed frustrating to provide care that is effectively spat upon by the receiver of that care.

This debate has come up over the years in different ways in other posts.  We've become a society that expects others to do for us.  One of the areas this is seen is in pharmacology: there is a medication for just about everything, even those ailments that could easily be reversed by conciensious personal health care decisions.

Your point about arbitrary caps is well taken.  That's taking the easy way out.  Not all smokers get lung cancer or COPD.  There are people who have lung cancer or COPD that have never smoked.  You punish the innocent with any cap.

Here is another consideration.  If you have 2 two-pack a day smokers x 20 years and one is sick and the other is not, there has to be another factor at play.  So, you could say even those who get sick doing a harmful activity are victims of heredity.

We used to have free wellness visits, now they charge for them.  Where is the incentive to go in and stay healthy?  Why should I not save my money until I "really need" health care?  I think we took a step backwards with that move.  If wellness visits and tests were free, more illnesses would be caught at early stages, saving money in the treatment of more advanced disease.  There could also be an incentive to routinely making well visits and adhering to the doctors' suggestions.

Darren and I were talking about healthcare delivery today and some unique options.  I think the answer to your question would be a complete overhaul of the system, one that would turn conventional healthcare delivery on its nose.  I think it would require a Cameronesque approach - changing the culture so it demands a change.  Perhaps we are on our way.

The challenge that will be inherent in any overhaul, whether it be medical delivery or immigration or taxes, is what to do with the interim.  There has to be a transition that deals with those entrenched in the current system.  I think in all of these situations, we get paralyzed in our thinking when it comes to the transition so we just throw our hands up and stay the course.

Janey Goude October 26, 2011 7:38 PM

Perhaps physical therapy organizations could think of several diagnosis (prognosis) they will deem nonemergent and perhaps refuse to treat after three session with no improvement.  

I appreciate the thought of why treat someone who is self destructive but if we do not treat are we modern day Kervokian adovocates with state authority to allow deaths by non treatment.  

Or should we try to save lives and ease suffering by any means necessary?

Great post and discussion Dean.  

Jason Marketti October 26, 2011 2:58 PM

Jason, many people on Medicaid use the ER as a primary care option. It is a VERY expensive option. There are programs, unfortunately aimed mostly at the frail elderly and not universal, which promote care management and primary care which have done well to improve outcomes and reduce costs in New York. Simply not treating someone to reduce costs seems really poorly thought out.

Most children don't suffer from COPD or have strokes due to smoking, drinking and overeating. Children are also lacking capacity to make those decisions so denying them treatment is not part of my question. However, by continuous cycling through the system of those who are unwilling to take any action to improve their own health only depletes the resources available for people like the parents and children of whom you speak.

The chain smoker with COPD who has recurrent chest infections and hospitalizations is the one cavalierly using up the funds. The money simply isn't there to treat everyone for infinity, not even here in the UK and NHS. So yes, there will be suffering ahead. I suppose my question is, who should bear the brunt of it? How will it be decided who gets treatment and who doesn't? Arbitrary targets and caps are not a good way to approach anything. There was a crisis here in the UK for that very reason, the Mid-Staffordshire Trusts caused many deaths by adhering to strict (but meaningless) caps. The hospital has now been shut and all the staff is under legal and professional scrutiny.

So what will we do?

Dean Metz October 26, 2011 12:03 PM

Washington State is limiting Medicaid patients three visits to the ER.  The fourth visit they must pay for.  The state wants to save money.  Physicians worry about patients self diagnosing themselves.  Washingtons Health Care Authority created a list of 700 non-emergent diagnosis not endorsed by physican groups.   Lots of children use Medicaid in Washington State.  Is non treatment an option for those who are suffering?

Jason Marketti October 25, 2011 9:30 PM

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    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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