My step-grandfather found himself in a similar position about 5 years ago. He'd been diagnosed with terminal cancer, and was in for a long decline. He opted to refuse food, and died within a few weeks. Sadly, that's the only option available to many who are ready to move on.

I remember him comforting his wife and daughters, telling them not to be scared, even as he lay hallucinating and dying. He'd lived a good life to an old age, and he was ready.

We owe our parents better. Death is a part of life.

Several of my grandparents had dementia of one sort or another. They clearly could still enjoy life, but completely differently than when they had their faculties. I wonder, if you could have gotten the question through to them, if they would have felt their lives weren't worth living. It doesn't seem the same question to ask a 30-year-old, "would you like to keep living at age 80 with no short term memory?" and to ask an 80-year-old with no short term memory, "is your life worth living?"

http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.htm...

Heisen-audience-loss-tracking I suppose.

Doctors peddle their wares on a piecework basis; communication among them is haphazard; thinking is often short term; nobody makes money when medical interventions are declined; and nobody is in charge except the marketplace.

No. This is not true. If the marketplace were in charge, the people who got the service would control and be responsible for paying for it by making free and informed decisions. Instead, this is a case where regulation is in charge -- payments are made based on arbitrary rules set forth by well-meaning people. People who might read articles like this and think gee, if we only made up a few more rules, or had some really smart guys in charge of the right stuff, we could fix these other unintended consequences we made last time we mucked around. There is no need for some uber-doctor who could somehow take the place of the buyer. There is nobody who can effectively take the place of the buyer. That's one of the main structural problems of the system. It's not that the marketplace is working -- it's that we've perverted and destroyed the marketplace and instead we have a free-for-all for handouts based on policies created by whatever gets votes. Which will continue to get worse.

Wonderful writing, though. I am always amazed at the capacity of folks to see their entire life experience through their own filters (including me) regardless of what the actual facts are. I hope writing this helped her reach closure and say goodbye

When did an efficient marketplace for medical services ever exist in the United States? "Buyers" have always depended on the ethics and professionalism of doctors; very few people have the education and sophistication necessary to second-guess them. People have always tended to trust doctors, if only because it was the least bad option, and when they don't trust doctors, the result is a thriving market for superstition and quackery. So if the buyer's decision is reduced to which doctor to trust, then you need a way to compare doctors' performance. Creating a way to compare doctors' performance would be a big undertaking requiring some kind of unified, centralized push for standardization -- almost certainly by the government.

There may be other ways to actively construct an efficient market, but simply removing the perverting force of regulation will not restore a previously existing efficient market, because the market for medical care has never been efficient, regulation or no.

Patients, even in the information age, cannot yet synthesize enough information to generally be intelligent, independent consumers of medical care. There is too much bogosity that has to be filtered out, and most people aren't good at that. (What??? Drug X killed 1 person once??? Well I'm not taking it! [Nevermind that Drug X has saved hundreds of thousands of lives.]) I don't think I'm being elitist, because physicians suffer the same problems, though perhaps to a lesser degree. While they might be more informed consumers of health care generally, a cardiologist probably doesn't have any strong, evidence-based opinions of which is the best treatment for their cancer. (I mean, besides fearing doxorubicin.) Their training in understanding the primary literature is probably their only advantage (and their training in outdated chemotherapeutic agents from medical school is probably their major disadvantage).

Most people don't know anything about cars, nor are even able to comprehend the complexity of your average vehicle, yet through trusted 3rd-party sources manage to find and purchase these extremely complex machines in a mostly-free market. Maybe as a future doctor you can explain why trusted third-party certifications would not emerge to protect the public if the government stepped out of the process? (I am genuinely curious)

If someone is trying to sell me an angioplasty, how am I supposed to decide for myself if I need it? Unfortunately, guessing wrong about the necessity of an invasive procedure is more risky than choosing the wrong fuel additive. No consumer guide can answer that question - and if it can, it can just label itself "medical school" and I'll respect that. Let's say that some guide says "angioplasty does not reduce mortality except in the setting of unstable angina or myocardial infarction, so don't get it." The doctor could come back and say, "yeah, but you have diabetes and that guide didn't look at studies with patients with diabetes." (Stuff like this is true and critically important to understanding clinical trials.) Or maybe you have atypical vascular architecture so the guides don't address that. I'm basically trying to get at clinical equipoise. Clinical equipoise occurs more often than you might think; it's a time where well-meaning doctors can disagree with one another because there is not specific enough data (or none at all) to answer the question at hand. I don't see a guide handling that.

(Note that I'm saying nothing about whether or not patients can choose physicians intelligently - I think they do it quite well via word of mouth - but I'm referring specifically to the consumption of medical care like medicines and procedures.)

> Note that I'm saying nothing about whether or not patients can choose physicians intelligently

I don't think I communicated very well... I was referring almost exclusively to this. Even this might be too specific... picking a good "provider" (e.g., a "brand", one level above a physician) might be the best an individual could do (since evaluating an individual physician might be too difficult).

It's all academic, really. Since the government pays for medical services directly (via Medicare and Medicaid) it's a given that the government has to pay for a huge organization to vet the individuals and groups its reimbursing. This means there's not as much of a "hole" for the private market to fill...

(I gather the dealers used to be this option---expensive but trustworthy---but it seems that lately dealerships are franchised with little enough oversight that you can't really trust them either; the Honda dealership near me is particularly shady.)

I find this a dubious claim. We have entire thriving industries of third parties who evaluate complex products and services. I don't see how medicine is any different in that respect, from, say, finance or engineering.

(1) Objectively assessing the severity of illness, regardless of what illness (or constellation thereof) the patient had. (2) Objectively assessing the degree to which a physician's intervention improved an outcome, and the distance between the true outcome and the best outcome (and the null / no treatment outcome).

I think that those two make medicine qualitatively more difficult to quantify in a useful fashion. (Though there are lots of useless ways to quantify medical interventions and physicians.) If you think you have some good ideas for solving those two problems, you have the chance to become very rich; please contact me if so (seriously).

Of course I am probably just being paranoid. We should instead head back to the good ol' free market medicine days, when anyone could put anything in a bottle and sell it as a patent cure-all. Back then people lived way longer, and had way better options for medicine.

Please note: I'm not saying the system isn't messed up, I'm saying you solution really isn't much better.

Also, I suggest you should only trust them to some extent. You need to understand the information well enough to make the decisions, like the mother in the story, where at the end, she treated the doctors as expert technicians, but she knew only she was responsible for the decisions of her life. Even if you have an excellent doctor, your life is your own responsibility.

I think the point is not the pacemaker. But the elongation of life and not seeing death as a good thing. If we always chose to prolong life, under any circumstance, then people profit (a dying person needs lots of medical care) and their caretakers only suffer. The person, I don't know, is it better to live with a half-working brain? Is it even living at that point?

I think while people want to live, people need to face death early, and tell their loved onces what their wishes are. And hopefully this sort of situation won't happen, or not for long.