Raising Medicare Eligibility from 65 to 67

U.S. Senators Lieberman and Coburn recently proposed raising the Medicare eligibility age from 65 to 67.  This would help save hundreds of millions of dollars.  





While this is obviously incredibly politically controversial, it is probably easier to cut eligibility than it is to cut benefits.  Richard Lamm recently wrote that "seniors have long expected Cadillac care for a moped premium."  Perhaps the Cadillac care will continue.  But fewer will get it.  And they will have to pay at least Subaru premiums.

Richard Lamm on End-of-Life Rationing

Writing in Sunday's Denver Post, former Colorado Governor Richard Lamm writes that "[r]ationing is the price an aging society must pay to prevent health care from crowding out all other public needs."  We should, Lamm argues, "shift our emphasis from quantity of life to the quality of life.  If we put death in perspective and use fewer desperate measures to extend life, we would free up money to spend on improving the quality of our lives."  

Lamm argues, among other things:

• No nation can escape weighing costs and benefits and setting limits on marginal care.


• No citizen can expect, in this time of technological marvels, public programs or insurance companies to pay for all the health care that modern medicine can provide.

"We can't allow everyone to attempt to buy immortality with public money."

Can rationing possibly be rational?

Lauren Vogel has just published the 17th in a series on end-of-life care in the Canadian Medical Association Journal.  This is a nice review of the growing professional and public conversation about health care rationing, especially of intensive care.  

Hospital Policy on Medical Futility — Does it Help in Conflict Resolution and Ensuring Good End-of-Life Care?

Singaporean neonatologist Roy Joseph has published a nice literature review in the January 2011 Annals Academy of Medicine Singapore.  The full text is freely available here.  Here is the abstract:

Introduction: This paper aimed to ascertain if hospital policy on medical futility helps in conflict resolution, and in ensuring good end-of-life care.

Materials and Methods: Literature on the subject published in the last 5 years was identified through Pubmed, and those with empirical data pertaining to the outcomes of interest were examined. A systematic analysis was not possible as papers varied greatly in aims, designs, outcomes and their measures. Instead, the outcomes of representative papers were described and discussed.

Results: There is a widespread use of policies and guidelines based on the concept of medical futility. Conflicts are rare and appear to arise primarily from the manner in which policies are implemented. End-of-life care appears to be improving as evidenced by a significant number of deaths occurring following: (i) discussions involving patient, family, healthcare team members; (ii) cessation of intensive care and (iii) cessation of institution of palliative care. Deaths are increasingly taking place in the presence of family and outside the intensive care wards. Finally, post mortem audit of processes and practices indicate (i) compliance but in a limited manner with policies and recommended guidelines, (ii) family satisfaction and (iii) identify areas where improvement in end-of-life (EOL) care can be effected. Key areas are in improving education of, communication with, and documentation by all stakeholders.

Conclusion: Hospital policies on medical futility have helped to resolve conflicts and improve end-of-life care. Prospective, multicentre and controlled trials will be useful in determining the value of specific interventions, obtaining generalisable data and facilitating implementation of better end-of-life care models.

Modernizing the Code of Medical Ethics

Last Monday, the delegates AMA Annual Meeting attended an open forum by the Council on Ethical and Judicial Affairs.  The topic of discussion was "At what point should physicians say “no” to their patients?"  

The delegates also discussed CEJA's project to modernize the AMA’s Code of Medical Ethics. “The Code needs to be user-friendly and organized in a way that you can put your finger on what you need, when you need it,” said Sharon Douglas, MD, who moderated the forum.

Patients over 80 Do Not Benefit from ICU

French researchers have found, in an observational prospective cohort study, that there was no benefit of ICU admission for very old patients (over 80 years old).  Researchers focused on long-term survival, than hospital survival, to investigate potential ICU benefit.  (Archives of Internal Medicine 171(12):1116-1117)

End-of-Life Decision Making and Care of the Dying Patient

Every two weeks, the American College of Chest Physicians issues a PCCSU (Pulmonary Critical Care Sleep Update).  Each one features timely, concise, diagnostic information on current pulmonary, critical care, and sleep medicine issues.  The second PCCSU in June 2011 is by Yale University Medical Critical Care Director Mark Siegel.  It is titled “End-of-Life Decision Making and Care of the Dying Patient."

The objective of his brief review is to highlight effective approaches to end-of-life decision making and palliative care in the ICU.  Here are his objectives:

• Explore the key ethical principles that underlie sound end-of-life decision making.


• Consider the key structural components necessary to implement effective triage policies.


• Discuss futility as a rationale for unilateral decisions to forgo life-sustaining therapy.


• Address common sources of conflict between ICU physicians and patients’ family members.


• Highlight key features of effective palliative care in the ICU setting.