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Arthur T Knackerbracket has found the following story:
Since Canada legalized Medical Assistance in Dying (MAiD) in 2016, as of Oct. 31, 2018, more than 6,700 Canadians have chosen medications to end their life.
Canadians who meet eligibility requirements can opt to self-administer or have a clinician administer these medications; the vast majority of people choosing MAiD have had their medications delivered by physicians or nurse practitioners. Canada is the first country to permit nurse practitioners to assess for medically assisted dying eligibility and to provide it.
The precise meaning and implications of MAiD—in particular, who can request medical assistance in dying in Canada—is still evolving through court rulings. Québec's Supreme Court recently struck down the reasonably foreseeable death requirement under the Criminal Code and the end-of-life requirement under Québec's Act Respecting End-of-Life Care.
Without the requirement of a reasonably foreseeable death, it is likely that other legal challenges will occur to extend assisted dying to other groups such as those whose sole underlying condition is severe mental illness.
Our research has explored how the nursing profession is regulating the new area of responsibility towards medically assisted dying and how nursing ethics might guide policy and practical implications of nurses' experiences.
Current legislation guards the right of health-care providers to conscientiously object to participation in MAiD. Nurses who do conscientiously object have a professional obligation to inform their employers of that objection, to report requests for MAiD, and to not abandon their clients. They also must ensure that their choices are based on "informed, reflective choice and are not based on prejudice, fear or convenience."
The nurses who surround the process of medically assisted dying are an important source of insight into the complex and nuanced conversations our society needs to have about what it is like to choose, or be involved with, this new option at the end of life, and to be involved in supporting patients and their families toward death with compassion.
Our most recent research involved interviews with 59 nurse practitioners or registered nurses across Canada who accompanied patients and families along the journey of medically assisted dying or who had chosen to conscientiously object. Nurses worked across the spectrum of care in acute, residential and home-care settings.
[...] With the changing landscape of medically assisted dying in Canada, the need for reflective conversations becomes ever more urgent. We need to better understand how medically assisted dying changes the nature of death to which we have become accustomed and how those changes impact all those involved.
(Score: 4, Insightful) by JoeMerchant on Sunday September 29 2019, @02:12AM (3 children)
Meaningless anecdote, N of 1, follows:
I had a debate with a newly minted M.D. who was doing his residency, making boatloads of money moonlighting here and there, driving his fancy new car on dates with only the best bimbos Miami Beach had to offer, and this young gem of a human being took the stance: "who cares if mammograms cause breast cancer, which they categorically don't (far from proven at that time), but even if they did, they absolutely increase the odds of detection which means we can treat it, cure it, and save lives - if we're causing some amount of breast cancer in the process, that's completely irrelevant because the treatment is so effective." Neglecting those who get mammograms up until they actually get cancer from them, then stop and die from the cancer induced by the detection - that's their fault for not continuing medical supervision like they're supposed to, neglecting issues of quality of life involved in the time spent screening and surgery that would otherwise be un-necessary, neglecting the risk of death under anesthesia, neglecting the risk of exposure to MRSA and other lovelies encountered while in the hospital environment... for him it was clearly about practicing medicine (getting paid) as often as possible.
Lots of people do, indeed, go into medicine to help people - they tend to have a much higher and faster career burnout rate than the one that go into it for the MONEY!
Absolutely, paid, paid well. Go-getter, specialist entrepreneur business owner M.D.s should be top 1% earners. Unfortunately, they are incentivized to treat, treat, treat, to get paid, paid, paid, rather than simply helping people who need it and leaving those who are better off without medical intervention the hell alone. Many of them do follow that model of prescribing for maximum personal income, within the guidelines established by their none too medically conservative peers. In my personal experience, while trying to avoid the money spinners and stick with the good hearted souls, I'm currently running about 80% money spinner in my M.D. interactions.
The AMA should be put on trial for crimes against humanity for the psychological selection and grooming process they have established to perpetuate the M.D. as God complexes that abound throughout our hospitals.
Don't they, though - implicitly? Delay and denial of necessary treatment happens, and it's mostly down to reimbursement, not availability of resources. Not in medically induced death, but in treatment of serious diseases.
Back in the early 90s, my grandfather had a near-death experience at age 72 - after 2 weeks in the hospital, they changed his meds, put him on bloodthinners which restored circulation to his brain and gave him mental clarity like he had when he was 60, and sent him home. Over the next year he thought a lot about what was probably coming - a relapse of the condition leading to amputation of a leg, or death - and he firmly made up his mind that he would not let them cut off his leg, he didn't want to live that way, he didn't want to burden the world that way, and he had spent a decade taking care of a bedridden parent from age 55-65, so... he knew firsthand what it was like... The attending M.D. was in disbelief, couldn't possibly approve it, but let my grandfather have his way against medical advice. As everyone knew would happen, gangrene set in and there was a painful week and a half while that ran its course. A week of that week and a half was un-necessary suffering for all involved, but legally required. My grandfather had made his peace months earlier, and the family had all come and said their goodbyes in the first 3 days after he went in the hospital, the last 7 days he was doped up and the rest of us were just on vigil. We got him in the ground 36 hours before Hurricane Andrew struck, what an unholy mess that would have been if he didn't die for another week.
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(Score: 2) by All Your Lawn Are Belong To Us on Sunday September 29 2019, @09:55AM (2 children)
So how was the guy making money personally off of doing mammograms? In case you weren't aware, residents aren't independently paid based on their billings. Yes, this is a little disingenuous because residents are liable to their supervisors who are very much paid based on their billings... But the meat of your anecdote is the resident arguing that more people are cured of breast cancer because of mammography than the overall risks posed by the procedure to screen and diagnose. That reflects more upon the ideal of recognizing that "do no harm" means something more ethically involved than, "do nothing invasive." If it did not medicine as you know it would not exist, because many of the things done in treatment actually do cause harm - but are done with beneficence because overall greater therapeutic returns are expected when screening X or procedure Y are done about condition Z - for the overall population. It's also why medical practice changes - when mammograms are done has changed significantly since you had that conversation in the 90s. But I've digressed seriously.
That doesn't quite match my experience for outpatient interactions. Starting from the principle that physicians don't simply go out and dig up patients, "Hi! you look like you could use a diagnosis and treatment today!" A person must first seek out care or have an event that causes an ambulance ride. It also doesn't match either outpatient or inpatient models of billing, at least for the basic management of a patient's condition. If you are not actually having a procedure done (actually the vast majority of patient treatments involve no procedures) and there isn't any kind of "quality incentives" at work, then your billing is based upon the complexity of the physician visit. And if you're inpatient the primary source of your charges centers around the diagnoses that are established. It's when the physician starts doing things after the evaluation that starts racking up costs.
OK. Then when do we put people on trial for allowing themselves to see the MD as God? That is very much a two-way street rooted in a person's fear of pain and death.
No, they don't. Not in the Republican talking point of "death panels" - which was a very convenient fiction. On this level reimbursement and resource availability are pretty close to equal, based on simple supply and demand. The more availability, the lower the price. The more efficacy at a lower cost, the more readily approved the procedure. Yes, they make decisions like, "A treatment which only works to improve the patient in 5% of cases over a 5 year span is not worth the expense paid on behalf of the 95% for the remainder." Or decisions like, "We can pay for product A which costs half again as much as product B, yet product A has not been shown to produce any more clinical benefit than product A." - and you can substitute "procedure" for "product" there. That's different from making arbitrary decisions about who lives and dies. I'm not defending that process as something good, as I believe there are better alternatives to structure medical care - I'm very much a supporter of government-supplied single payer. But the rationing process is not done solely with the intent to make money. And there must be a rationing process unless the floodgates of supply can be opened, which would very much take government action.
That sounds like it was an incredibly stressful experience, and I'm sorry for the suffering y'all went through. Thank you for sharing that story. Was hospice care involved at all? I would have thought that at some point (especially when gangrene set in and he refused treatment) that it could become a matter for that type of care. (Not to mention, today, one could discharge from hospital once further restorative options were off the table). Deaths attended by hospice can also be trying and painful, just ones where the suffering is minimized to the lowest extent possible. Medically assisted death does not work very quickly, for the simple fact that one doesn't want a rush to judgment.
This sig for rent.
(Score: 2) by JoeMerchant on Sunday September 29 2019, @02:19PM
No, they don't, but you could clearly argue that drug companies (and others) endlessly exhort persons "suffering" all manner of common life complaints to "ask your doctor about..." And, once in the office, that's where I've met 4/5 doctors who appear, based on their recommendations to me, to be seeking payment over patient well-being. An extreme case in point: I had an unexplained and bothersome lump, went to an ENT and asked him about it, he was perplexed, but suggested we take a biopsy. While tugging on it for biopsy, 90+% of it came out: win-win. Sent it to the lab: Schwannoma, benign. Great, now we know - he's in the 1/5 category: did what I asked, reasonable progression of procedures, recommended followup in 1 year. During the following year I moved 1000 miles away, did my followup with an ENT in the new town, sat in the waiting room for 30+ minutes while reception checked, then rechecked my insurance (from a big company located 2 miles from his office, but, I suppose they just like to be sure), heard the confirmation of payment come through the receptionist's phone, and moments later I'm called back. "Oooh, yes, schwannoma, very scary, can lead to a string of pearls condition, you want to get the rest of that out of there, I have an opening in my surgery schedule next Tuesday, let me take care of that for you, I'll cut the whole thing out so it won't come back..." So, at the time, a Google search (not even flipping PubMed, straight up Google), leads to a top result of a documented case of one Japanese fisherman who had a string of pearls schwannoma present between his ribs after an injury... extensive deep searches through the medical sources and Google never find another single mention of schwannoma string of pearls. Dude has an opening in his surgery schedule and he's going to fill it with me because I have presented at his office with A) insurance that will pay, and B) something he thinks he can scare me into letting him cut on my tongue for no good reason. Followup with another ENT 2 years later: nothing to worry about, come back if it starts growing quickly or gets big enough to be a bother, no followup recommended. Oh, and by the way, just cutting a big margin around a schwannoma doesn't guarantee non-recurrence, often the act of cutting will trigger a restart of growth. She was another of the 1/5.
Osteopath, surgically took care of a nasty crush injury for me, but, inexplicably, left a bone chip in. Saw it on the followup X-ray, asked: "what's going to happen with that" - the normally confident and outspoken MD sort of mumbled an evasive response. After spending 6 weeks of followup therapy in the clinic he coincidentally owns, that bone chip presented at the surface in a pustule of green ooze: osteomyelitis - with a recommendation of followup surgery to "take care of it". The particular procedure he performed normally has a 2 week recovery time, and a post surgical infection rate far below 10% - procedure was well documented back in the 1970s as an "office based" thing, but, practices have apparently changed over the years and now we need a full blown surgery, in the physician owned surgical suite, with general anaesthesia, etc. and, somehow, infection rates from that setup are far worse than the office based practice of the 1970s, but, hey, today we have physician owned MRIs to look at the infection with, and elastomeric ball based IVs so the osteomyelitis patients can still go to work during their 6 weeks of treatment... he was clearly in the 4/5, far too many of his patients were referred for post-surgical osteomyelitis treatment, and his methods are ballooning his reimbursements while doing nothing of value for the patients - at least from the perspective of the patients I met while under his care.
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(Score: 2) by JoeMerchant on Sunday September 29 2019, @03:05PM
I don't see it that way, at all, and most nurses and other sub-M.D. medical staff I have interacted with concur: they are only Gods in their own minds, otherwise they're pretty much PHBs blind to their own shortcomings - but with the one power: to utterly destroy your career, so you might as well play along with their delusions if you want to be able to pay your rent.
I have noticed a severe reduction in the seeking of second opinions over the decades, and I believe the insurance based reimbursement structure has heavily contributed to that. IMO, as insured patients, any time a procedure with potential for negative effects and outcomes is recommended, it should be our covered by insurance right to seek a second, and possibly third opinion when the situation calls for it. But, with 6+ week delays involved in seeing specialists and astronomical (5x, 20x, 200x) costs of "not covered" anything in the medical profession... we seem to be being steered into accepting whatever the first doc tells us. Attribute some of the time delay to the AMA again, and their inadequate residency capacity leading to undersupply of little gods-in-their-own-minds, but the insurance oriented billing farce where private pay can literally be more than 100x as expensive as "allowed" charges under insurance, that is just a disconnect from all reason. By the way, I don't hate all doctors, I worked for a very good man (who the staff literally nicknamed God) for 12 years - chief of medicine at a major hospital, top of his field, etc. I've known many good pediatricians and primary care docs. But, so many quacks, so many ego cases, and to stretch the field a bit, so so many greed based dental practices.
Fun recent case in point for insanity rooted in the insurance reimbursement model: a drug company has discovered that compounding of dextromethorphan and quinadine has beneficial effects for brain chemistry of a fairly wide spectrum of patients, but so far they have only sought approval under the Dx of PBA. They did three PBA studies (a very easy to study condition), maybe a couple of hundred patients enrolled, and now they're approved to market the drug. Know what old cough syrup + more or less tonic water goes for in a pill these days? $1200 per month. That system is broken, and, luckily in this case, I believe easily circumvented with a compounding pharmacy - though we haven't verified that yet, still evaluating the drug's effects so far it seems good.
Yes, basically as soon as the M.D. accepted my grandfather's wishes he was transferred to an in-hospital hospice wing. The condition that got him was an aneurysm in his femoral artery, all other arteries to that leg had already shut down and when this one clotted and didn't respond to treatment, that was it, no circulation to the leg. The condition was present a year earlier and they were able to treat it with clotbusters, eventually, but not the next time. The hospice care was good, the only complaint we had was that the final week was just pointless - the decisions all made, everybody at peace with what was coming, just having to live through it for a week with him in such a bad state and no real chance of recovery other than him changing his mind to take off the leg, anyone who knew him knew he was far too stubborn to change that decision, and he was in such an altered state from the pain meds that he really couldn't make any decisions anyway. If he weren't so stubborn it would have been even more agonizing if he flip-flopped while on the meds and started asking to be saved, only to change his mind back after he was lucid again, and utterly tragic if they did take his leg off and save his life just for him to commit suicide on his own later.
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