5 ms·

Outside of the other comments here, I would also suggest considering the expected outcomes rather than just whether or not someone will live and die. For examp

by kxyvr 4y ago

Outside of the other comments here, I would also suggest considering the expected outcomes rather than just whether or not someone will live and die. For example, if someone spends a month on ECMO and the end result is that they're neurologically devastated, require a feeding tube, tracheostomy, and get discharged to an LTAC, was it worth it? If someone can never have a conversation again, or hold they're children, or read a book, was it worth it? If someone is likely to die, is it worth it to break their ribs or cover them in their own blood and fluid when they code? Given how sick someone is when they're put on ECMO, these are all realistic and likely outcomes. And, look, this is a value choice that families have to make, but also one that most have not considered before getting sick and don't really want to consider when they're thrown into that situation. Physicians know about these likely outcomes, so it affects their opinion about its use. As a brief aside, if anyone does end up in this situation, it's stressful and I'm sorry that you're going through this. Really. If I could offer one unsolicited suggestion, it would be to discuss the possible and likely outcomes with your physician, beyond life and death, so that you can make an informed decision that's best for your family.

vkou 4y ago
Not to mention the costs. Medical resources are limited, and in a country where we are chronically under treating people, it makes no sense to torture someone with an ECMO for a month, only for them to 'recover' to the state mentioned above. That money/medical effort could have been used to save/significantly improve the lives of dozens of people, instead of prolonging the death of one. It all comes out of an insurance pool, it's not like people are bearing ECMO costs out-of-pocket. It all comes out of the same labour pool, when you've got your entire medical staff put on hopeless cases, there are people who could be helped who are being denied treatment.
- nradov 4y ago
  We are both chronically under treating some patients and over treating others. Over treatment is a leading cause of iatrogenic harm. Some providers default to aggressive treatment whether due to a sincere belief that it's best for the patient, or to satisfy patient requests, or to make more money. But evidence based medicine guidelines indicate that it's often best to do nothing beyond active monitoring of the patient's condition. https://dx.doi.org/10.1371%2Fjournal.pone.0181970 https://dx.doi.org/10.1371%2Fjournal.pone.0181970 Ideally we should be allocating limited medical resources based on formulas that maximize overall benefit as quantified by quality-adjusted life years (QALY). But it's politically difficult to set rational policies around rationing care without triggering toxic disputes about "death panels" and "killing grandma".
kurthr 4y ago
To give some color. I haven't heard that marginal costs are ~$5000/day, I have heard they are closer to $20k/day. Granted other procedures were involved, but one ECMO stay was over $12M for 4 months. That is closer to $100k/day. How many other people could you save (even within the same healthcare system) for that kind of money? These long tails have huge impacts on insurance costs.
- throwaway6734 4y ago
  Yep that's insane. That's the same as giving 1,000 families $1000 a month for the first year that their child is born. Surely that would have a significantly larger positive impact on society
- jessriedel 4y ago
  > I haven't heard that marginal costs are ~$5000/day, I have heard they are closer to $20k/day. To be clear, I wrote >$5k, not ~$5k.
conductr 4y ago
No supporting data other than my decades working in healthcare and having conversations with coworkers versus my non healthcare working family/friends. I’d say those in the medical community that have been more exposed to what that altered reality looks like, tend to not want it for themselves. That is to say, they’d rather expire. They’d probably also use that info to inform choices they made for loved ones in a similar situation. The general population is very mixed but there seem to be more folks on relative basis that would keep someone alive at all costs or try anything to save them regardless of the risk. I also think sometimes it just comes down to medical professionals being able to come to grips with the reality of the situation and make a hard decision when others default choice is keep them alive /try anything. Aside: I worked in a hospital from 18-25 and have basically seen it all as my job had me in every department caring for every patient and I notice when something crazy happens I still have the ability to not be consumed with shock but assist. I recently saw a pedestrian/auto accident and was on foot myself. About 30 folks around saw it happen. Everyone froze or turned away in disgust. I ran and basically took control of the situation until EMTs arrived. This has happened a few times in my life and I can’t help but to correlate it to my exposure to the hospital environment.
jessriedel 4y ago
> Outside of the other comments here, I would also suggest considering the expected outcomes rather than just whether or not someone will live and die. I take this to be obvious.

by kxyvr 4y ago

vkou 4y ago

Not to mention the costs. Medical resources are limited, and in a country where we are chronically under treating people, it makes no sense to torture someone with an ECMO for a month, only for them to 'recover' to the state mentioned above. That money/medical effort could have been used to save/significantly improve the lives of dozens of people, instead of prolonging the death of one. It all comes out of an insurance pool, it's not like people are bearing ECMO costs out-of-pocket. It all comes out of the same labour pool, when you've got your entire medical staff put on hopeless cases, there are people who could be helped who are being denied treatment.

nradov 4y ago
We are both chronically under treating some patients and over treating others. Over treatment is a leading cause of iatrogenic harm. Some providers default to aggressive treatment whether due to a sincere belief that it's best for the patient, or to satisfy patient requests, or to make more money. But evidence based medicine guidelines indicate that it's often best to do nothing beyond active monitoring of the patient's condition. https://dx.doi.org/10.1371%2Fjournal.pone.0181970 https://dx.doi.org/10.1371%2Fjournal.pone.0181970 Ideally we should be allocating limited medical resources based on formulas that maximize overall benefit as quantified by quality-adjusted life years (QALY). But it's politically difficult to set rational policies around rationing care without triggering toxic disputes about "death panels" and "killing grandma".

kurthr 4y ago

To give some color. I haven't heard that marginal costs are ~$5000/day, I have heard they are closer to $20k/day. Granted other procedures were involved, but one ECMO stay was over $12M for 4 months. That is closer to $100k/day. How many other people could you save (even within the same healthcare system) for that kind of money? These long tails have huge impacts on insurance costs.

throwaway6734 4y ago
Yep that's insane. That's the same as giving 1,000 families $1000 a month for the first year that their child is born. Surely that would have a significantly larger positive impact on society
jessriedel 4y ago
> I haven't heard that marginal costs are ~$5000/day, I have heard they are closer to $20k/day. To be clear, I wrote >$5k, not ~$5k.

conductr 4y ago

No supporting data other than my decades working in healthcare and having conversations with coworkers versus my non healthcare working family/friends. I’d say those in the medical community that have been more exposed to what that altered reality looks like, tend to not want it for themselves. That is to say, they’d rather expire. They’d probably also use that info to inform choices they made for loved ones in a similar situation. The general population is very mixed but there seem to be more folks on relative basis that would keep someone alive at all costs or try anything to save them regardless of the risk. I also think sometimes it just comes down to medical professionals being able to come to grips with the reality of the situation and make a hard decision when others default choice is keep them alive /try anything. Aside: I worked in a hospital from 18-25 and have basically seen it all as my job had me in every department caring for every patient and I notice when something crazy happens I still have the ability to not be consumed with shock but assist. I recently saw a pedestrian/auto accident and was on foot myself. About 30 folks around saw it happen. Everyone froze or turned away in disgust. I ran and basically took control of the situation until EMTs arrived. This has happened a few times in my life and I can’t help but to correlate it to my exposure to the hospital environment.

jessriedel 4y ago

> Outside of the other comments here, I would also suggest considering the expected outcomes rather than just whether or not someone will live and die. I take this to be obvious.