Eyeworld

EW NEWS & OPINION 20 July 2015 Insights by J.C. Noreika, MD, MBA consider them? Must we first con- cede "death panels" before discus- sion ensues? In 1996, after deliberating for 2 years, the physicians, ethicists, policy experts, and economists of the U.S. Panel on Cost-Effectiveness in Health and Medicine endorsed QALYs as a methodology "for iden- tifying and assigning value to health outcomes." Fourteen years later, the Patient Protection and Affordable Care Act (ACA), famously passed so we might learn what was in it, proscribed its Patient-Centered Out- comes Research Institute (PCORI) "from developing or using cost-per- QALY thresholds." In 2013, Medicare consumed more than 14% of the federal gov- ernment's $3.5 trillion apportion- ment. Of the $583 billion in benefits paid out, physician reimbursement amounted to only 14%. But that "only" is qualified by my patient's story. Decisions made by her prima- ry care doctor, surgeon, and family cost exponentially more than the physicians' compensation. Accord- ing to the Center for Medicare and Medicaid Services, more than 25% of Medicare expenditures are con- sumed in the last year of a patient's life. Used more judiciously, these dollars might ensure the program's future viability and make a contribu- tion toward insuring the uninsured. It is time that fantasy and poli- tics yield to wisdom. It is time that physicians promote compassionate dignity when ministering at their patients' end. It is time these ines- capable duties commence. My patient? She "shuffled off this mortal coil" without regaining consciousness. The pathologist's report? The mass was benign. EW Reference 1. Neumann PJ, Weinstein MC. Legislating against use of cost-effectiveness information. N Engl J Med. 2010;363:1495–1497. 2. The Patient Protection and Affordable Care Act. PL 111-148. 3-23-2010 Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com Euthanasia need not enter a debate for judgment, common sense, mercy. I believe all life pre- cious but our nation, founded on the Judeo-Christian tradition, must conduct a serious debate about when preciousness ends and death's inevitability intrudes. Because med- ical technology is limitless, the law ambiguous, families irrational, and politicians expedient, this dialogue must include ethical, responsible physicians when life is in extremis. In 2006, David Brennan, then CEO of AstraZeneca, was quoted, "Americans have a unique sense of entitlement to healthcare not seen in the rest of the world, and regard dying as a choice." He may have been paraphrasing British wit and polymath Noel Coward. It is true. Had she lived in Cana- da, Sweden, or anywhere else in the world, exploratory surgery on this patient's pancreatic lesion would have been unthinkable. In the United Kingdom, the Care Quality Commission of its National Health Service (NHS) has a coordinated net- work of boards and committees that audit the quality and appropriate- ness of care. Approval of the initial CAT scan instigating this travesty would have been unlikely. Is the NHS's National Institute for Health and Care Excellence's re- liance on quality-adjusted life years (QALYs) and other nomographic models so sinister, so threatening that Americans can't be trusted to She was referred by her primary care doctor to a general surgeon and with consent of family, underwent an exploratory surgery to define the radiologic shadow. If cancer, what was the plan? What outcome might be expected? What and to whom comprised informed consent? The hours-long surgery was performed under general anesthesia. When she left the operating room, my patient was physiologically alive. During her stay in the surgical intensive care unit, she no longer responded to nurses or family. She did not die. She endured 5 weeks, never regaining her preop- erative state of bewilderment. She was transferred from the acute care hospital to a long-term bed in another hospital until her life mercifully ended. I visited her a few days before she died. Alone in the muted room, I watched the IV bottle drip, heard some monitor of negli- gible importance, was aware of the slow, shallow rattle of life's end. She was unaware of my presence. Her sightless eyes were closed; she did not respond when I spoke to her. It was devastating on many levels. Euthanasia is a slippery slope that a society hazards to judicially condone a narcotic-induced death. I think Ezekiel Emanuel, the academic spokes-doctor for the defense of the Affordable Care Act, ludicrous for headlining an article in The Atlantic, "Why I hope to die at 75." Nuncle, the hubris! In an era of seemingly unlimited medical technology, this true story highlights the urgency to temper potentially life- extending surgery and science with respect for a person's right to die with grace and dignity T his report is not about euthanasia. Since 1994, 5 states voted or its courts ruled to permit physician- assisted dying. At least 4 European countries have legally adopted the right to end one's own life. In early 2015, Canada legalized physician-assisted death. The subject demands a thoughtful hearing; that awaits another day. I had a patient, a relative of a close friend. A decent woman, she lived too long. As often happens, after the death of her life partner, she began the inexorable downward spiral to her own demise. At the end, I was her eye doctor. At 92 years old, she had advanced glaucoma not treated soon or well enough to prevent sight impairment. Cogni- tively, she rapidly descended into dementia's gloaming. A once proud woman, she relied upon the kind- ness of others to maintain a modi- cum of vitality. I confess not knowing how it all went down. But I did witness the consequences of decisions that, in retrospect, were at best questionable, at worst, horribly inappropriate. Since I last saw her, she had experienced some abdominal discomfort and refused to eat. Her inventory of ailments exceeded only the pharmacopoeia of medications prescribed by her panel of physi- cians. This happens. Then the story turned. She underwent a CAT scan of her abdomen. The image showed a mass on her pancreas. Cancer? And, if cancer, a curse or blessing? The indignity of an American death J.C. Noreika, MD, MBA

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