Cost, death, benefit analysis...

[CharonY]

Oh yes the limits indicate are a benchmarks throughout private and public health insurers.

[tuco]

The real question, to me, is who gets to decide this point, respectively who would want to be the decider?

[CharonY]

4 minutes ago, tuco said:

The real question, to me, is who gets to decide this point, respectively who would want to be the decider?

Which point? The non-resuscitation decision? AFAIK that has to be done by the patient or those with the equivalent of a power of attorney (but for health decisions). Public insurers usually have a cut-off above which they do not approve life extending procedures, when the added QALY is low. Private insurers use it as a guideline to establish cost and depending on your premiums they may have a variety of measures to limit payments (e.g. simply by having a maximum coverage). Private insurers (especially for group insurance) can therefore only pay for part of procedures regardless of  QALY added (which is why medical bankruptcy also often happens with insured folks). 

 

[tuco]

The point where the cost outweighs the benefit. 

btw can you point me to where I can read about this cut-off because I have not heard about it before. 

[StringJunky]

7 minutes ago, tuco said:

The point where the cost outweighs the benefit. 

btw can you point me to where I can read about this cut-off because I have not heard about it before. 

https://en.wikipedia.org/wiki/Quality-adjusted_life_year

[CharonY]

40 minutes ago, tuco said:

The point where the cost outweighs the benefit. 

btw can you point me to where I can read about this cut-off because I have not heard about it before. 

In addition to the link provided, you can read up on the NHS here: Collins & Latimer BMJ 2013; 346:f1363. In the US there are no strict threshold (in fact there are legislation against its explicit use) but there is a history of thresholds used as informal yardsticks. The rather interesting history is summarized by Crosse Expert Rev Pharmacoecon Outcomes Res. 2008 Apr;8(2):165-78. Note that predictably there is intense discussions surrounding cost-effectiveness calculations in healthcare, ranging from availability and quality of data to use of models to calculate effectiveness of treatments.

Edited April 10, 2018 by CharonY

[tuco]

I see, thanks. Well, that ends the thread  answers the OP or?

[OldChemE]

I think the OP question is answered, but would point out that DNR decisions are not the only way government guidelines bring life to an end on a cost-benefit basis.  A good friend of mine was diagnosed with operable prostate cancer at the age of 79.  His doctor and insurance company refused to recommend or support prostate surgery.  The basis given was that, according to US Government and Medicare protocols, a person of his age did not need the surgery as he would likely not die of the cancer anyway.  This was, in effect, a cost benefit analysis.  He was a healthy alert man of good mind.  He could not afford the surgery on his own.  Untreated, the cancer spread outside the prostate gland and killed him in 4 months.

[CharonY]

20 minutes ago, OldChemE said:

I think the OP question is answered, but would point out that DNR decisions are not the only way government guidelines bring life to an end on a cost-benefit basis.  A good friend of mine was diagnosed with operable prostate cancer at the age of 79.  His doctor and insurance company refused to recommend or support prostate surgery.  The basis given was that, according to US Government and Medicare protocols, a person of his age did not need the surgery as he would likely not die of the cancer anyway.  This was, in effect, a cost benefit analysis.  He was a healthy alert man of good mind.  He could not afford the surgery on his own.  Untreated, the cancer spread outside the prostate gland and killed him in 4 months.

Well that is highly unusual and sorry that it happened. Typically, the prognosis of prostrate cancer is very good and more people seem to die with prostrate cancer rather than because of it. Obviously it is difficult to tell whether misdiagnosis happened (i.e. it was already far more advanced) or it was just one of the rare aggressive cases. Typically, though early detection triggers active surveillance in every 3-6 months and when growth is monitored on of the various options of treatments are used. Especially in very old persons surgery is not the best option, as it may carry higher risk than the cancer itself. Instead, radiation therapy is often used in early stages, for example. Under these conditions the 5-year survival is close to 100% and 10-year still around 98%. Fatal progression within 4 months is incredibly rare.

That being said, the thinking has been changing as modern operative techniques have lower morbidity than they used to have and some are starting to operate on older patients. However, patient selection is still important to make sure that there are no other comorbidities. As a whole the cost is probably not what failed your friendbut rather the common medical risk assessment. 

 

[Prometheus]

I don't think the OP has been answered. Currently any decision regarding CPR by NHS staff involves only the probability of success and projected quality of life thereafter - it never involves financial considerations. The question is whether it should: it's not really the kind of question that can be definitively answered.

QALY is not used in the day-to-day assessment of patients (at least in the NHS). It is used by NICE to rationalise the price of treatments, but i do not think they have ever assessed CPR . I did come across this US study though which estimated the price of one QALY for octogenarians at ~£44,000, which is above NICE's threshold for cost-effective treatment, which has an upper limit of ~£30,000. By these numbers there could be a case for not offering CPR to people over 80 on the NHS but that kind of 'one size fits all' approach might mean some 80 year olds who would potentially do well post-CPR are essentially being discriminated against based on age.

[CharonY]

Of course, emergency or even routine treatments of illness do not generally fall under these rules. It is more specifically used to approve certain life-prolonging procedures (and again, CPR does not fall under this). Also, the value is not a hard threshold. Experimental drugs, for example can exceed these guidelines, IIRC. More commonly are e.g. drugs that are not expected to prolong life sufficiently for the given value (with a minimum life extension of 3 months) or as a tool to assess new interventions. 

 

[Prometheus]

Yes, CPR is not covered by this which why i was wondering whether the OP wanted to extend the discussion to withdrawal of care or just focus on CPR.

If just focusing on CPR i'm not sure how practical it would be to ask health professionals to factor in financial considerations as well as clinical. Some guidelines would have to be made. Alternatively an awareness campaign into the realities as CPR might do the same job. Healthcare professionals are much more likely not to want CPR - no reason to think the general population would not think the same way when exposed to the same realities.

[dimreepr]

24 minutes ago, Prometheus said:

Yes, CPR is not covered by this which why i was wondering whether the OP wanted to extend the discussion to withdrawal of care or just focus on CPR.

I'm happy for the discussion to evolve.

6 hours ago, Prometheus said:

By these numbers there could be a case for not offering CPR to people over 80 on the NHS but that kind of 'one size fits all' approach might mean some 80 year olds who would potentially do well post-CPR are essentially being discriminated against based on age.

I was thinking on a case by case basis depending on the prognosis on admission.

[CharonY]

48 minutes ago, Prometheus said:

Yes, CPR is not covered by this which why i was wondering whether the OP wanted to extend the discussion to withdrawal of care or just focus on CPR.

If just focusing on CPR i'm not sure how practical it would be to ask health professionals to factor in financial considerations as well as clinical. Some guidelines would have to be made. Alternatively an awareness campaign into the realities as CPR might do the same job. Healthcare professionals are much more likely not to want CPR - no reason to think the general population would not think the same way when exposed to the same realities.

To be fair, CPR seems to have only a relatively low success rate in either case. But ultimately the decision here is down to the individual. And in emergency situations there is rarely time to make holistic assessments.

[dimreepr]

7 minutes ago, CharonY said:

To be fair, CPR seems to have only a relatively low success rate in either case.

 

Doesn't that depend on where the patient is?   

 

[CharonY]

Yes, the rate is higher in hospital. But the average is still around 20% (and I think somewhere around 10% outside hospitals). It depends on the situation, of course and the rates are not negligible. But they are not that very high, either. 

[Prometheus]

15 minutes ago, CharonY said:

To be fair, CPR seems to have only a relatively low success rate in either case.

That would be part of the awareness campaign.

 

5 minutes ago, dimreepr said:

Doesn't that depend on where the patient is? 

Even in hospital CPR has a very low 'success' rate - success being simply to get the heart beating again. I think it's something like 3% of CPR survivors will return to a near normal life.

 

15 minutes ago, CharonY said:

But ultimately the decision here is down to the individual.

Check out point 10 of this document:

Quote

It is not necessary to obtain the consent of a patient or of those close to a patient to a decision not to attempt CPR that has no realistic prospect of success. The patient and those close to the patient do not have a right to demand treatment that is clinically inappropriate and healthcare professionals have no obligation to offer or deliver such treatment.

Should be noted this is far from the norm. But ultimately healthcare professionals can choose not to resuscitate. 

Edited April 11, 2018 by Prometheus

[CharonY]

Just now, Prometheus said:

Check out point 10 of this document:

Fair enough. However, I was more referring to an actual no resuscitation order rather than non-medically indicated attempts.

[Prometheus]

15 hours ago, CharonY said:

Fair enough. However, I was more referring to an actual no resuscitation order rather than non-medically indicated attempts.

Not sure i get your point. That document refers to actual in-hospital do not attempt resus orders. By non-medically indicated attempts you mean out of hospital attempts by by-standers?

[CharonY]

5 hours ago, Prometheus said:

Not sure i get your point. That document refers to actual in-hospital do not attempt resus orders. By non-medically indicated attempts you mean out of hospital attempts by by-standers?

No I meant, the actual order as a legal document when a patient declares that they do not want to be resuscitated (for whatever reasons) even if it could be medically indicated. Your link refers to the whole decision frame work which does include situations that are purely based on medical indication (i.e. when there is no expectation of success). 

[dimreepr]

4 minutes ago, CharonY said:

(i.e. when there is no expectation of success). 

Or, when there's no intention of success. 

[StringJunky]

27 minutes ago, dimreepr said:

Or, when there's no intention of success. 

When might that occur?

[dimreepr]

19 minutes ago, StringJunky said:

When might that occur?

Sometime tomorrow... 

[koti]

1 hour ago, dimreepr said:

Sometime tomorrow... 

Who knew.

[jajrussel]

I would hope that if they just needed to keep me alive long enough to heal, then keep me alive. If it becomes apparent that I'm not going to heal, or I'm simply dying of old age then let me die. Preferably painlessly, without convulsions, or spasm. If it's doctors making the decision, I shouldn't have to sign a do not resuscitate form. It's the in order to save money decision that is unethical whether private or national Healthcare System.