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Comment by asdfj999 | Hacker News Reader

If I could change one thing about healthcare, it would be how we handle end of life care. Sadly, hospitals are full of 80-90+ year old people who cannot walk or talk for years, advanced dementia plus many other serious comorbidities, with severe malnutrition and recurrent aspiration pneumonia, with large non-healing sacral ulcers, who shit and piss themselves, and the family continues to insist we "do everything" to help this person. It is by far the most demoralizing part of working in healthcare, in my opinion, and an astronomical amount of expenditure and effort goes into torturing these people - at the direct order of the family - only to prolong suffering a few more months.

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I suspect this happens in the UK too, although doctors (in my very limited experience of this) do tell families the truth about what they can do.

I think there is a cultural problem about facing up to death, because people do not talk about it. It is a taboo subject to many, and people use euphemisms a lot (which is always a sign of a topic people do not want to talk about).

We need much better end of life care. Hospices seem to do a great job (no experience from the patient and family end, but I knew someone who used to work in one) but there are not enough of them.

> I think there is a cultural problem about facing up to death

It definitely is culture problem, just look on average police chase in USA followed by a news helicopter. The moment when suspect crashes, news camera will start wildly zooming off and panning away. Why is that? You don't want to see the end of chase, where a guy is getting crushed by momentum of his car, while he could stop and get arrested anytime during the chase? Show the consequences of his actions and tell that if he would not try to run, he would likely be still alive. Arrested, maybe little bit beaten by the cops, but alive.

I read a comment on here a while back that highlighted EoL care as the main way The Machine has to sap resources between generations, and it makes a lot more sense when looked at through that lens. I don't see it going away any time soon since its a guaranteed process for every person that moves wealth away from the lower/middle classes into the industry at a grand scale.

How much of that is The Machine, and how much of that is kids & grandkids not wanting grandma to pass away?

For what it's worth, when my grandma was in the hospital with congestive heart failure, the surgeon was very clear with her and with us that "do nothing, and die" was very much an option, and a choice that she and she alone could make.

Often the family dynamic is that the next-of-kin who have the power to make end-of-life decisions hesitate to cut off care even when they know it is pointless or cruel because they're afraid of being criticized by other family members later. Sometimes this extends to vicious backbiting and cutting off contact. I've seen these issues break extended families apart. It takes a strong and confident person to take responsibility in this situation, and then accept the consequences.

That's true. Grandma initially wanted to get no treatment, and boy did we hear about it - the rest of her family convinced her to go ahead and undergo treatment.

I think this was the correct choice, but I have no idea.

On the one hand, she's feeling much better now, and I'm glad she's around, because I like spending time with her.

On the other hand, the recovery was pretty rough, though thankfully she doesn't really remember the truly bad parts. And she's 90 years old, and has repeatedly stated that she doesn't particularly want to go on living.

On the gripping hand, the doctor's description of letting yourself die of congestive heart failure sounded rather unpleasant, and hopefully instead of undergoing that, she'll pass away in her sleep.

On the hands that I'm running out of, maybe an even worse fate awaits.

Can't see the future. :/

Until you have to make that decision it’s easy to judge. Even if you think you are doing the right thing for someone that can’t speak for themselves, the guilt can stick with you.

People really need to consider the alternative though. I've seen a lot of old people who were desperate to depart this world but whose younger relatives wouldn't let them.

In most places is it even possible to give these people mercy and opt them out of life if they and/or the family wanted to?

At least in the US, in general we talk to the family about code status "Do you want your loved one to receive CPR if their heart stops?". We can make them DNR/DNI. Then next discussion would be hospice. They would have a hospital bed sent to their home, be discharged with a weekly nurse visit and doctor available by phone/text, and get minimal medications focused on minimizing suffering.

DNR: Do Not Resuscitate DNI: Do No Intubate

>Sadly, hospitals are full of 80-90+ year old people who cannot ... and the family continues to insist we "do everything" to help this person.

so what? It is on their dime, not yours. If i'm a 90 years old and wanna drag my existence out it is my choice as long as i'm paying for it, directly or through insurance (and Medicare is an insurance too btw)

It is easy to suggest to terminate lives earlier when it isn't your life. History is full of such attempts.

One should be glad that such a large sector of economy - healthcare - has a great stable demand and a great labor market. Overwork - teach more nurses and doctors. The issue is completely self-inflicted as the labor supply is artificially constrained:

"In 2023, U.S. nursing schools turned away 65,766 qualified applicants from baccalaureate and graduate programs, according to the American Association of Colleges of Nursing (AACN)"

In my experience it is rarely the patient making this choice. Much more often the children, who are often making a big show of how much more they love mom or dad compared to the other sibs.

And the patient made that choice by establishing that family dynamics and by not having specific instructions even while seeing over decades the family dynamics they created themselves. I'd say that is an explicit clear choice. And anyway it isn't outsider's business to tell a family how to care for their own.

> And the patient made that choice by establishing that family dynamics and by not having specific instructions even while seeing over decades the family dynamics they created themselves.

Most people who are old today (or in the last few decades) probably wouldn't have thought about it because it wasn't something that affected their parents who likely didn't live that long in the first place.

Very naive take.

Patients' children regularly override the patient's clearly expressed wishes once the patient no longer has decisional capacity.

> so what? It is on their dime, not yours.

Actually in Europe it is on a dime of a taxpayer so also his.

No, they paid into it their whole life. So, it is their dime not the current taxpayer’s. The taxpayer is paying for their own future.

That's not how state pensions or state healthcare works.

Which is why we should be against taxpayer-funded healthcare: You don't get to make some of these decisions because you aren't paying for it.

Medicare is not insurance. The word "insurance" has a specific meaning, and the traditional Medicare fee-for-service program doesn't meet that definition. (There are a variety of other payers or health plans in the US healthcare system which fill a similar role to insurance but are not actually insurance.)

ok, call it a contract between an individual and society - the individual pays taxes today and when retired gets his/her medical needs taken care about by the society. Looks like an insurance contract to me, btw.

Anyway, like with any contract, whatever the individual is due under that contract is his dime, not the taxpayers'.

It doesn't matter what you're due under a contract if the counterparty is insolvent. Medicare beneficiaries are going to have to accept reduced benefits and higher fees. This is unavoidable due to demographic changes.

the society reneging on its contract today means that the current taxpayers will lose the trust in the society and in particular will be significantly discouraged from paying taxes, etc. as they would lose belief in the society keeping its side of the bargain in the future.

It doesn't matter whether taxpayers are discouraged. Medicare taxes are automatically deducted by employers for most workers.

taxpayers are voters. So it does matter a lot if they are discouraged.

> One should be glad that such a large sector of economy - healthcare - has a great stable demand and a great labor market.

This is not the tourism industry, a “great stable demand” is sick and suffering people.

The hospital has limited resources, which are being taken up by people who have no hope of getting better (they ain’t getting younger). A push to do everything we can to stop them from dying buys us what? A few more months of pain and delirium before we reach the same result.

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