HEALTH CARE COSTS---saving patients from death due to cost-containment

FINANCIAL MOTIVES FOR CHOOSING AN EARLIER DEATH

    Every health-care system—whether public or private—
has administrators who must manage the health-care resources
in order to achieve the most good for the most people.

    These administrators do not usually know the patients personally.
They are looking at computer screens
that show the amount of medical resources already spent
on patients whose names or identity-numbers
mean nothing to the administrators.

    When these administrators are government officials,
they are making sure that the taxpayers' money devoted to health-care
is being spent as wisely as possible.

    For example, money saved by omitting questionable terminal care
can be redirected toward pre-natal care for pregnant women,
who would otherwise be at risk of having children with health problems,
who will cost the taxpayers even more if their problems require life-time care.

    When these administrators are executives of insurance companies,
they are responsible for limiting the amount of money paid out for health-care
so that the stock-holders will have a larger profit at the end of the year.
If they are 'too generous' with the cash in the vault
—if they pay out 'too much' for the health-care of the policy-holders—
they will be replaced by other executives who manage the costs 'better'.

    When the administrators are hospital executives,
they know that there are only a certain number of beds in the hospital
and in the intensive care unit (ICU).
When the demand for care exceeds the supply,
they must decided which patients to shed
in order to achieve the greatest good for the greatest number of patients.
This sometimes means taking an intensive-care bed
away from an elderly dying patient
in order to devote those same staff and other medical resources
to saving the life of a young mother of three children.

    Administrators must operate according to abstract principles
rather than personal feelings.
And many of those abstract principles are financial:
What is the best use of the medical resources at my disposal?
Since the resources will always be limited,
choices must be made to treat one patient
and allow another patient to die.

PROTECTING AGAINST HEALTH-CARE ADMINISTRATORS

    Careful safeguards can prevent premature deaths motivated by money.
The safeguards that would counter-balance the financial incentives
call for the considered judgment of persons
not subject to the same financial pressures as health-care administrators.

    Here are eight safeguards that might be effective against cost-cutters,
beginning with the most powerful.
The blue title links to a complete explanation of that safeguard.
The red comments explain how that procedure
deals with the specific problems raised by cost-containment.

PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

    The terminal-care physician in charge of the dying patient
will know the particulars of this patient's prospects,
which can counter-balance the need to control health-care costs.
Does the physician's statement describing the patient's condition
support or challenge the administrator's wish to save money?

REVIEW BY THE PROSECUTOR (OR OTHER LAWYER)
            BEFORE THE DEATH TAKES PLACE

    If the need to save money is the pivotal factor favoring death,
the prosecuting authority will probably veto the plans for death
by telling the administrators that they will be prosecuted
for causing premature death if they proceed with the plans for death
primarily motivated by the need to save health-care dollars.
The public prosecutor puts the life of the patient before anything else.

CIVIL AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH

    Employees of government agencies, hospitals, & insurance companies
should not consider themselves immune from prosecution
in case their decisions lead to premature death.
When the most egregious cases of 'pulling the plug' to save money
come into public awareness and before the courts,
then health-care administrators will be warned away from
harming patients in order to save money.

REQUESTS FOR DEATH FROM THE PATIENT

    If the patient has made documented requests for death,
health-care administrators can show
that such requests were independent of the need to save money.
If the patient asks for death in order to preserve his or her estate,
this also is a questionable reason for choosing death.

INFORMED CONSENT FROM THE PATIENT

    Likewise, if the patient has given fully-informed consent for death,
this would be evidence against any complaint
that the patient is being put to death for economic reasons.

UNBEARABLE SUFFERING

    Those who are aware of the intolerable suffering of the patient
will put this factor above any economic issues.

ETHICS COMMITTEE REVIEWS THE LIFE-ENDING DECISION

    The ethics committee of the same hospital
might find itself at odds with the administrator.
If and when this happens, this is a yellow light,
telling everyone to go slow with respect to end-of-life planning.
A truly-independent ethics committee
can counter-balance any administrator
whose primary reason for wishing to 'pull the plug' is to save money.
The ethics committee will evaluate all the other factors
that are relevant to making a wise end-of-life medical decision.

STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

    Advocates for patients from disadvantaged groups
will almost always object to ending the life in question
when they suspect discrimination against a member of their group.
And all such objections must be taken into account
and evaluated on their merits.
Discrimination must not be tolerated,
whether or not it has any economic motive.
The written statements of any such advocates should allay any fears
of discrimination on the basis of group-membership
or because the terminal care is costing too much money.
If these special advocates approve the life-ending decision,
all more-distant doubters should be assured
that the timing of this death was not chosen for economic reasons.

created February 23, 2007; revised 3-9-2007; 8-28-2008; 11-1-2008; 12-18-2008;
1-30-2010; 5-21-2010; 2-25-2011; 12-21-2011; 2-18-2012; 3-25-2012; 5-29-2012; 9-11-2012;
3-17-2013; 6-20-2013; 7-16-2014; 10-10-2014; 11-7-2014; 4-24-2015; 7-3-2015; 2-9-2018; 8-16-2018; 5-22-2020;

    The Liverpool Care Pathway for dying patients
was used briefly in the United Kingdom.
When the patient was believed to be dying anyway,
curative treatments and life-supports were withdrawn,
resulting in an earlier death for the patient.

    This end-of-life plan had to be discontinued because it was abused:
Sometimes the medical staff chose the LCP
without consulting either the patient or the patient's family.
Local hospitals were paid bonuses
for putting patients on the Liverpool Care Pathway.
This did save money for the National Health Service,
but it was not always the best medical choice for the particular patients.

    Search the Internet for more information about the "Liverpool Care Pathway",
perhaps starting with the Wikipedia article:
http://en.wikipedia.org/wiki/Liverpool_Care_Pathway_for_the_Dying_Patient