Wednesday, October 28, 2009

When States Collide

While I haven’t read the book, I’ve been interested and sometimes amused at the title, What’s the Matter With Kansas.  You see, while I live in western Missouri (or as we commonly say, “On the Missouri side”), and my health system is headquartered in Missouri, the hospital I serve is in Kansas.  As a result, I pay attention to health news from Kansas with as much attention as from Missouri.

So, I didn’t miss this news item in my local paper: “Kansas state lawmakers push for health care insurance opt-out.”  It seems that three Kansas legislators have decided that any public option offered as a part of national health care reform would be an unacceptable trampling on states’ rights.  Moreover, they fear it will become a trampling on the rights of citizens (although whether they are more concerned about individual citizens or corporate citizens - i.e., insurance companies - remains to be seen).  To that end, they want to amend the state constitution to say that any health insurance mandate, whether requiring individuals to purchase health insurance or requiring employers to provide it, cannot be enforced in Kansas.

My initial reaction to this was that these state legislators were raising this issue only in Kansas.  In fact I was uninformed.  There have been efforts in other states for months now.  They are coming from conservatives who state they’re placing a high value on freedom to choose, including the freedom to choose not to purchase health insurance.  Thus, Federal individual and employer mandates are unacceptable.  In fact, for some apparently a Federal effort to make health insurance more affordable by offering a public option in a health insurance exchange, thus creating competition for private insurance companies, is somehow coercive.  So in many places efforts are being made to change state constitutions to prevent this perceived Federal encroachment.

Now, I will say first and foremost that, even if these constitutional changes pass in some states, I don’t see how they can stand for the long term.  I have already argued that all health is public.  Indeed, we’ve seen just how public it is in our current H1N1 flu pandemic.  With this, and with any contagious disease, we have reaffirmed that we are our siblings’ keepers, at least in this.  What I do to protect myself from getting the flu also protects anyone I might infect if I get it.  For me hospital patients are the special group for concern; but it also protects the grocery clerk and the waiter and the librarian whom I encounter, and even the grocery customer and the diner and the library patron who cross paths with me.  For much of our health care, we depend on a certain “herd protection.” 

It’s also the case that economically we are our siblings’ keeper.  We all pay for one another’s health care, whether it’s through taxes or insurance premiums or through the price increases brought about by losses for unreimbursed care.  That is already the case, and it won’t be changed by the reforms currently considered in Congress – or for that matter any reforms that weren’t considered.  Nor will it be changed by an attempt to prevent some government management of the competition among insurance companies.

A consequence of both these facts is that health care, and so reimbursement (or lack of reimbursement), is a matter of interstate commerce.  I am acutely aware of this in my position.  As I said, I live in Missouri but work in Kansas.  In fact many people in the eastern counties of Kansas find their health care in institutions in Missouri.  That’s a common enough occurrence in the Kansas City area, of course; but it’s also true farther south, where the larger towns and larger institutions are east of the state line.  While I don’t know the numbers, I can only imagine that in the far western counties folks who need intensive care find it in Denver or Colorado Springs.  I would bet, too, that some in the northeastern counties find it in Omaha or Lincoln.  So, in my part of the world health care is explicitly interstate commerce.

That is a regional expression, but there are other ways.  Think, for example, of the large networks of health care providers.  Such for-profit companies as HCA and Tenet are certainly interstate companies.  So are such religious networks as Adventist and Ascension.  Now, they deal already with differences between states.  However, they might find if difficult to do business in a state if it essentially establishes a population risking unreimbursed care.

One way or another, states that allow individuals to go without insurance, through lack of an individual mandate or of an employer mandate or through some other mechanism, will necessarily place burdens on institutions in other states, and so on citizens in other states.  That seems to me ripe for a decision from the Supreme Court; but that would take years.  It might take years, too, to change state constitutions; but one can only hope that those efforts fail.  Health care issues respect our political divisions no more than the illnesses that raise issues.  Let’s hope that most of our citizens, and the legislators that represent them, will see this clearly and take responsibility, not only for their own individual health needs, but also for the needs of their fellow citizens.

Monday, October 19, 2009

During the Festivities

While I don’t make reference to it here, folks know that the system and the hospital within which I work are named for the Evangelist who was also a physician.  This week in our system is Saint Luke’s Week, when we highlight the work of chaplains in the system.

One of the special events I schedule during Saint Luke’s Week is the Blessing of the Hospital.  Using a service modeled on house blessings, I walk through the hospital praying and asperging with holy water.

Today as I made my way through the hospital, folks noticed smoke coming from the hospital’s roof.  It was a simple mechanical issue with no risk to person or property.  However, we did get an immediate response from the fire department, which simply added to the concerns of observers.

At a later point, one of our administrators stopped me and, smiling, asked whether I thought my blessing was responsible for the smoke.  I said, “Well, I don’t know, but I suppose I might have hit something evil.” 

His eyes widened for a moment; and then he smiled.

Thursday, October 15, 2009

Curious Connection Up at Episcopal Cafe

So, my newest piece is up today at Episcopal Cafe. Just to peak your interest, this is the first sentence: "So, there I was, watching Project Runway, when I found myself thinking about Clinical Pastoral Education." Now, if that doesn't make you curious, I don't know what will.

So, go over and take a look at the Cafe. And while you're there, read what my colleagues have also written - read, and take the time to leave a comment. We're there to show just what good stuff folks in the Episcopal Church have to offer..

Tuesday, October 13, 2009

One Step - and On To the Next

Well, the next step has been taken. The Senate Finance Committee has voted out its health reform bill.

While this has gotten a lot of attention, I don’t really think it the significant step that the media makes it out to be. Certainly, it is interesting in that it managed to get a vote from a Republican senator, after involving three in the process of writing it. However, this is not the final bill, nor even the final Senate bill. There is another bill in the Senate, from the Health, Education, Labor, and Pensions Committee (the HELP Committee – no kidding!). There will be negotiations to blend these two bills, and that will become the Senate bill.

And then there is the House bill – and in fact there are three of those. HR 3200 has gotten a lot of attention, but it will have to be blended with two others to produce the House bill.

And finally there will be a Conference Committee. The bill produced by the Conference Committee and passed in both Houses in the same form will be the bill that gets to the President’s desk (see, I did pay attention to “Schoolhouse Rock”).

So, keep watching, siblings; and keep writing to your senators and representatives. This isn’t over until it’s over (and, really, it won’t be over until we see it implemented). Keep watching.

Wednesday, October 07, 2009

"If your only tool is a hammer...."

We have a new procedure at our hospital – well, new and not new. The principle has been around for – well, anecdotally, almost forever – but we have come to apply it again. It is also new to our setting.

This “new” tool is hypothermia: lowering the body temperature of a patient to slow metabolism. We’ve all heard the stories of the victim who fell through the ice on the pond. After time under water the victim is removed, cold and apparently lifeless. However, a pulse returns, and with time the victim recovers – not only physical function but mental function, too.

This has been done in hospitals in the past, and for varying conditions, but with varying results. Now, protocols have been developed, and in our hospital and many others it has become a new tool in cases of cardiac arrest when there has been some period with no pulse, and so with probability of loss of oxygen to the patient’s brain. The hope is to preserve brain. (You can see information about it here.)

Not long ago, I asked one of our cardiologists about the studies that had been done to demonstrate the value of hypothermia. I specifically asked about the results of those studies. He said that the success rate was about 10%. That is, the number of patients with good outcomes was 10% higher among those treated with hypothermia than among those who were not.

Now, in one sense, a 10% result may or may not be a big deal. If it’s the difference between respective recovery rates of 90% vs 99%, that’s important. If it’s the difference between 10% and 11%, how important is it? If it's the difference between 50% and 55%, how do we decide? And of course the answer to that question must take into account how devastating the disease (and let’s be honest: the neurological consequences of hypoxia caused by cardiac arrest can certainly be devastating), and whether it’s your loved one in the ICU bed.

That raises some corollary issues. The most important is, for which patients do we use this? The studies I’ve been able to find and look at (mostly in abstracts) are small, and address several different presenting diagnoses: cardiac arrest, certainly, but also cardiac arrhythmia, strokes, and neurotrauma. Some were more pilot studies of one sort or another, either to demonstrate enough response to be worth studying, or to look at different mechanisms for cooling and/or warming the patient. An important issue in research ethics is just how much we can generalize from one study to another – from a small study to a large one, from a procedural study to a treatment protocol, from one diagnostic patient group to another. It is also an important issue in moving from a study to a treatment protocol.

There are also issues around the duration of the protocol. You see, to commit to this protocol takes time. The patient must be gradually cooled to the appropriate temperature, maintained at that temperature for an extended period of time, and then gradually rewarmed. The point of the protocol is to protect neurologic functions, but those functions can’t be assessed until the patient has been sufficiently rewarmed. So, we’ve committed the patient and ourselves to two or more days of intensive care before we can really assess progress. If it’s successful, no one questions the value. However, if that 10% is a small margin in a situation of low expectations, one has to ask whether there has been an appropriate use of resources. There are issues of justice if we’re providing this lengthy and expensive protocol (in all resources, but money symbolizes them all) with little expectation of meaningful recovery.

We’ve also committed the family to two or more days of watching and waiting. During that time, there is little we can tell them. After all, the patient has been put on the protocol because of a devastating event. However, while the protocol is in process, we can’t really assess the consequences of the event, nor advise the family on what to expect. We speak often in health care about the difference between extending life and prolonging dying. If we can’t assess, how do we know which we’re doing, and what can we tell the family about that? We don’t want to give false hope – indeed, in my hospital that is explicitly stated in orientation to the protocol – but to engage the protocol at all is to offer hope before we can know whether it’s reasonable or false. I will acknowledge that this is true of all emergency medicine, and much intensive care; but that doesn’t absolve us of addressing this concern.

What this really presses us to do is ask when it’s appropriate to use the protocol. That really is a question of which patient is an appropriate participant: which diagnoses suggest it, and which related factors exclude it. The thing is that the studies don’t really clarify that. Once again, the few studies address a number of different presenting diagnoses, and those differences make a difference. In addition, any study also has exclusion criteria. A good study is looking at a specific, relatively narrow question, and not every patient would help answer that question. So, there are criteria for including a patient in a study group, and criteria for excluding. However, different studies have different exclusion criteria. That also makes the results hard to generalize. Narrow criteria for inclusion and variable criteria for exclusion add to the difficulty deciding which patients might benefit from this protocol for treatment. Can the patient be too young or too old? Are there other physical conditions that might affect the patient’s survival independent of brain injury, such as liver failure or metastatic disease? It’s possible to look online at hypothermia protocols from various institutions, and see that there are differences between their exclusion criteria (for example, here or here). So, once again, have we invested resources in patients who won’t benefit for reasons independent of this event? Have we offered hope to a family in a situation that is medically futile for reasons independent of this event?

So, how is it that we offer this protocol to our patients? The real answer is that the events are indeed as devastating as I’ve suggested. Loss of blood flow and of oxygen to the brain is devastating, whatever the cause. Our colleagues specializing in stroke have for some time encouraged rapid response to stroke symptoms with the phrase, “Time is brain;” and that’s just as true when it’s caused by heart attack or a fatal heart rhythm. So, in a situation where before we felt there was nothing we could do, now we have something we can try.

Which brings me back to the title of this post. Most readers will recognize the saying: “If your only tool is a hammer, every problem begins to look like a nail.” So it happens in medicine. As hard as we try to measure the effectiveness of treatments, and as hard as we try to be careful and scientific about it, we are also prone to the temptation to “do something, even if it’s wrong.” Or more clearly, we’re more likely to do something because we don’t know whether it’s wrong. I think of it as a special application of the ethical principle of the technological imperative: "we can do something, therefore we must." However, it’s also an application of my own comment on ethics: critical decisions are usually made emotionally, and justified rationally afterward.

The thing is, the technological imperative is a fallacy. It does not follow that because we can, we must. In this instance, we must consider how to use this tool, to optimize the benefits it can offer in light of the costs both in resources and in the emotions of patients and families. Indeed, we must consider these questions with any such tool in health care – something we do reasonably well with drugs but not so well with new procedures or devices. And I would argue it is even more important when the circumstances are devastating; for that is when we are most likely to invest our time, resources, and emotional energies in our actions.

So in my own work I watch and wait with families to see if this will help; and I celebrate with staff and families when it does. That also means I grieve with staff and families when it doesn’t; but that’s the nature of my vocation. And I do ask questions, trying to help focus on what can help, and on what extends life rather than simply prolonging dying. And I especially ask this question: is this problem really a nail, or is it just that all we have is a hammer?