Instrumented Interconnecteds Intelligent
August, 27th 2009

A lot of the commentary about Ted Kennedy’s death has focused on his involvement in health care legislation over the years, and has speculated about how his absence from the Senate might affect the current debate. But there’s another aspect of his death that is equally relevant to the debate….the manner of his dying itself.

Today’s New York Times contains reporting by Mark Leibovich that outlines how Kennedy controlled the process and the experience of dying, so that he would have a “good ending.” Yes, upon his initial diagnosis, he did take “prudently aggressive” treatments of surgery, chemo and radiation. But when it became clear in recent months that these would not halt the progress of the disease, he re-oriented himself to making the most of the days he had left, and apparently didn’t attempt heroic life-extending measures at the end.

If everyone who is in the final stages of a terminal illness did that…..just that….only that…….it would go a long way towards “bending down” the health care inflation curve. You’ve seen the statistics about what a high portion of Medicare is spent on people in the last six months of their lives. Obviously, each of us is going to be in that zone at some point. How we behave when we get there, the choices that we and our families make, will have a profound impact on our ability as a nation to pay for health care.

When my Father was dying of kidney failure at the age of 86 (ironically, in the Hyannis hospital, a few miles from the Kennedy compound ) it would have been quite possible to “save” him by putting him on near round-the-clock dialysis. But to what end? He had said all along, when he was still fully clear, that he didn’t want a life where he would spend most of his waking hours hooked up to a pain-making machine. And even in the fog of his actual dying, when dialysis was offered to him by the hospital staff, he didn’t accept. “I don’t know” was the diplomatic most they could get from him, a decline that to me reflected both his faith and his courage about taking “the big trip.”

But as medical technology invents ever more sophisticated (and more expensive!) ways of keeping people alive beyond their body’s natural abilty, I believe it will eventually come to a point where not just “Grandma”, but every single one of us, will have to ASK to have “the plug pulled”, or even turned it down in the first place. When that choice comes, let’s hope we can all follow Senator Kennedy’s example. If we don’t, there is no hope at all of controlling medical costs.

John Mihalec was a White House speech writer for President Ford, and an aide to US Senator Lowell Weicker and Illinois Governor James R. Thompson. He joined IBM in 1978, and has been a Vice President in IBM Communications since 1995.

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October 11, 2016
1:09 am

Oh The really God is no ending

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Posted by: venus factor coupon
September 13, 2013
5:11 am

It is cruel but it is true… But we do not know anything about world after death. And what will we feel be fore death. So we must very careful before making conslusions. So i do not know where is true…

Posted by: Lankstinukai
December 18, 2011
12:25 pm

I totally agree with you. I too wouldn’t want to spend the last of my days hooked on a machine. I wouldn’t look at it as giving up on myself and on hope but it is facing the reality.

Posted by: State Specific Living Will
November 10, 2011
7:19 pm

There are actually plenty of particulars like that to take into consideration. That is a nice point to deliver.

Posted by: cloud computing marketing
September 15, 2009
4:04 pm

Thanks for the comment,Knick. I suspect we wouldn’t have to worry about defining “cost-effective” if the patient or family were always responsible for 20%, or above a certain bar, 10% of the cost. It is the notion that someone else is paying for all of it that encourages people (and doctors!) to consume health dollars without any concern for effectiveness or probability of result. If we are moving to a world whether everyone is going to have their knees and hips replaced at some point in their lives, then we need a system where everyone is taxed, over their lifetimes, enough to pay for that, with high earners paying more and low earners less. There’s no free lunch in healthcare either.

Posted by: John Mihalec
September 15, 2009
3:46 pm

This is a very touchy topic, though much less touchy for a private company than the government to broach. The words “cost-effective” are not exactly warm & fuzzy as they pertain to human life. After all, is a handicapped baby a cost-effective entity? Is a paraplegic cost-effective? Is a person suffering from severe depression cost-effective? This opinion piece doesn’t get heavily into the ownership of the ultimate decision, but that’s the question it begs.

Posted by: Knickerbocker
September 1, 2009
9:23 am

You are right, Patrizia, that we don’t know how we will feel until it is our turn. I don’t think that a person’s last month is useless, but in fact very useful, if we acknowledge what’s about to happen. A great example of this is the fabulous books of poems by John Updike called Endpoint, many of them written in his last month when he knew he was dying of cancer, this past January. They reflect both the fear and the fulfillment of his situation without whining or desperation. Lotusflower, our prayers are with your brother. He should be getting whatever support is needed to make him most comfortable.

Posted by: John Mihalec
September 1, 2009
5:14 am

Seems to be an inhumane way of treating a very sick person, in our culture, that is; but I guess practical… I know and I cry everyday because my brother who is ailing with colo-rectal cancer refuses to get medical help any longer and just want to die at home.

In this country, not everyone owns a medical insurance. We are 3rd world, you see.

Earlier, my brother obtained a loan to pay up his hospital bills where he was initially being treated for his cancer complications.

Right now, I cry… for his 3 young children who will soon loose a father.

Posted by: lotusflower
September 1, 2009
1:27 am

I understand your point.
I am 57 and right now I fully agree with you.
Why spending “$140,000 that is extracted from the resources available for other human lives, including the saving of lives that can be lived for more than a week. ”
I really do not know how I will feel when I am ACTUALLY the one.
Do you think I would just say “I should just die, because every day of my useless life is going to cost so much for the community…”
Or “fuck the cost, I paid all my life and I do not feel guilty if THEY have to pay for me…”
Or just” I do not think this is life and I do not want to live if I have to suffer so much…”
Who knows?
I hope I will never be in the situation to think or say any of these.

Posted by: Patrizia Broghammer
August 31, 2009
11:20 am

Well, Patrizia, that’s what makes horse races. And blogs. I don’t seen anything unpleasant at all about pointing out that one of the major contributing reasons for medical costs to be so high in the US, and getting higher, is the expanding ability of medical technology to tease our primal human desire to live forever. I don’t care how mentally alert or free of pain I maybe be at the end (I’m 62 now), I don’t want to live an extra week at a cost of, say, $140,000 that is extracted from the resources available for other human lives, including the saving of lives that can be lived for more than a week. Dying in a more natural and historic way has EVERYTHING to do with managing medical costs, even if it’s only part of the solution. And I was shocked to read a while back that people who have a strong religious faith are generally MORE (not less) likely to opt for heroic life extending measures when death was imminent. Go figure.

Posted by: John Mihalec
August 31, 2009
2:37 am

Since the dawn of humanity, man has faced the reality of death and the fear of it.
Religion means just that: the answer to our big questions, why we are here and what will happen after.
Religion and faith should help us to face the moment of the big jump, and also the thought of getting closer to it.
I guess that depression and indolence in old people are mostly due to it, to the realization that the feared moment is close.
I always thought that big suffering had at least one good side: you actually WANT to die, because life is unbearable.
But I am on the side of helping the dying to face a human death, and if possible not to face it at all.
I am 57, and after my parent’s death I think often about getting older and dying.
My father had Alzheimer and in one way I would like to follow his steps.
He had a much better death than my mother (she died for lung cancer) because he didn’t even realize he was dying.
He had a good and relatively long life; he faced death without seeing it.
Death should be like that: the same as birth, a fact of our life we do not actually live.

Your article is a good one, but there is a very unpleasant note in it: “If we don’t, there is no hope at all of controlling medical costs.”
Dying in a human nice way should have nothing to do with controlling medical cost….

Posted by: Patrizia Broghammer
August 28, 2009
10:36 am

I agree with just about everything said here. Education is key,and counseling should be available to all. These end of life decisions have to be made, but it should always be decided by the patient, the patient’s family and the doctor. It will be a sad day if we delegate fundamental life decisions to the government and insurance companies.

Posted by: Jeremy Hodge
August 28, 2009
3:47 am

Well, of course the “systematic change” being considered in the current healthcare debate is (or rather was) end of life counseling, which got willfully mistranslated into “death panels” by individuals opposed to the the overall legislation and seeking to derail it. But that’s what political people do, so before anyone gets too self-righteous about it, let’s remember that Senator Kennedy himself used the same sort of egregious hyperbole to derail the Supreme Court nomination of Robert Bork (“In Robert Borks’s America……etc.”) Much as Senator Kennedy has been widely and justifiable praised for working across the aisle on legislation, he could throw around the partisan invective with the best of them. But I believe the current horror about “death panels” will yield over time to a larger social realization that end of life counseling is good for everyone because we are all going have an end of life, and it matters socially and personally and financially how that is managed.

As to who makes the decision to “pull the plug”, obviously our universal view is that it should be the individual or alternatively the next of kin. And we honor that today even at gargantuan costs in many cases. But we may well come to a point, hastened by technology, where we as a nation can no longer afford to do that in cases where consciousness is not existent and there are no reasonable hopes of improvement. At which point it would be government’s responsibility (because most of these situations involve Medicare)on behalf of all of us to say, based on consistent standards,in essence: you can keep the machine going if you want, but from now on, it’s your nickel. I don’t see anything unreasonable about that when the alternative is bankruptcy as a nation.

Posted by: John Mihalec
August 27, 2009
10:32 pm

Wonderful perspective John, and nice comment, Derek.

In both cases, your parents seemed to have the foresight (and time) to think through these things in advance. Often, many don’t seem to have that foresight or time.

So how does one (or a state, or a regional hospital system, etc) translate that into some systematic change in our health system?

It seems one thing is providing better, cheaper, (mandated?) access independent counseling for terminally ill patients and families. It’s in the health insurance industry’s best interests to do that. It also seems that, as Paul Grundy talks about so often, a patient centered system, where the patient, with the doctor, is in control, could help bring misaligned interests (doctors get paid for tests and procedures so if they don’t have a strong patient relationship).

This also gets into some challenging areas too, though, namely, who makes the ultimate decision. Solely the patient? Or the insurer, or a regulatory entity?

Regardless, thanks for the provocative post.

Posted by: Adam Christensen
August 27, 2009
9:04 pm

This post hits home for me. My grandmother had expressed many times that, when her time came, she just hoped she “didn’t linger,” and fortunately had her children and some of her grandchildren (one of whom is a doctor) there to be sure her wishes were honored as that translated (or didn’t) into heroic measures, DNR orders and the like. Not having sons bright enough to go to medical school, my mother had a very explicit “living will” that spelled out to what degrees she would and would not accept extending her life through artificial means — yet as it turned out, she was able to decline going back on the ventilator for a third time for herself.

I celebrate that, with the right choices, the right genes, and probably some individual luck, we can live longer today than previous generations. And I can still feel short-changed that my mom died at 65. But above all, I feel certain that one element of a good life is, at the end, a good death. I fear such a thought or conversation isn’t just awkward for some people today, but is actually considered distasteful and impolite, regardless of where it’s brought up or by whom.

We tread in uncharted waters here for such a blog, but personally, I think it’s a moral mistake to put a dollar value on a life or even just another year of it. I think it’s just as bad a moral mistake to continue life artificially when it comes at the cost of all our other values.

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August 31, 2009
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