He understands the problem, can anything be done about it.

With all due respect, I'm not sure this is a great example of the difficult cost-benefit tradeoffs that have to be made with end-of-life decisions. This wasn't a case where you have to decide whether to spend $30k to extend life for two months with a crappy quality of life. It's a case where the choice is an average of six months of life with either a miserable quality of life or a reasonably good one. A society that doesn't pay for hip replacement for a terminally ill patient with several months to live ought to issue cyanide pills instead -- it's the only humane thing to do.

This is exactly the kind of thing the wingers are always ranting about. Nobody is going to support a national health care system in which their grandma might suffer unnecessarily as a matter of policy -- it's a bit too much like the system we have now. If you want a chance of having a decent health care system in this country, you will have to rely on other ways of cutting costs. Eliminate the profit motive, negotiate prices, figure out what the most effective treatments are and which ones don't actually work. But personally I'm not going to support a plan that takes treatment decisions away from doctors and patients.

I am not sure Obama got this exactly right and his decision is influenced by the limited perspective most patients and families take when faced with challenging medical decisions. Obama states that the choices are “a risky hip replacement surgery or waste away with a terrible quality of life [QOL]” – but this is a false dichotomy. It presupposes that a “good” QOL requires returning his grandmother to a condition akin to before the fall/fracture. However, a high QOL can still be enjoyed despite considerable limitations on prior abilities. (The prime example of this is surveys of healthy individuals on their perceived QOL were they to suffer a permanent spinal cord injury – many say life would not be worth living. However, surveys of actual parapalegics show that many of them lead rich, fulfilling lives.)
While we lack considerable information regarding her conditions and prior functional status, it is not impossible to envision alternative choices being made if more information was available and provided to the Obamas. Pain from hip fractures can be excruciating, but it is treatable and resolves over time (usually ~4 weeks). The reason for performing hip replacements for fractures is two-fold, to limit the time of disability and to prevent long term impingements on gait following mending. (Like most bones, if not severly displaced, the femur will mend; surgery developed because the complication rate is higher during the healing process.) Even if the surgery was successful, return to functional mobility requires considerable rehabilitation – which given Obama’s grandmothers terminal cancer and heart condition may not have been possible. Both treatment options may have ended at the same place -- with her requiring a wheelchair for mobility +/- pain control.
Why was this information not given to the Obamas, leaving them with the impression that there was no viable option except surgery? Cynics might say it is because orthopedic surgeons are paid to operate! While the payment system exacerbates many of the problems in healthcare, the larger problem is that doctors of all disciplines and patients/families are not well versed in goal setting at the end of life. Scientific evidence is limited as many of these types of decisions fall under the purview of palliative medicine – a relatively new field. Assume the surgery was flawless (limited blood loss to prevent significant fluid shifts that might strain her ailing heart, timely implantation of the prosthesis to limit anesthesia time and perfect adherence to sterile technique to avoid post-operative infection), we know the outcome was less than favorable. If the big picture of possible outcomes had been presented and a different path taken, there is no guarantee that the outcome would have been different. However, suppose a less invasive approach was used and she lived 3 months with more limited mobility but got to witness her grandson become the first black president of the United States, do you really think she would have considered the time wasted and of low quality?

I'm really surprised that no one offered Obama and his mother hospice care. The whole point of Hospice is to make the patient comfortable in their last months. And Hospice nurses have all sorts of tools at their disposal to do that, including special beds, wheelchairs, drugs, etc. BDS makes a good point when he/she says that Obama was given a false choice. Hip surgery or pain and suffering. That's really a shame.

The main reason she probably had surgery was for mobility and at a minimum less pain with transfers. Nonoperative treatment of displaced hip fractures in the elderly approaches 100%. Yes it may heal in 4 weeks, if they survive the self enforced bedrest. If they don't have pneumonia or a PE and get to 4 weeks there is no guarantee it will be healed enough for weightbearing particularly displaced femoral neck fracture. Four weeks is also an awful long time for someone who would probably rather lie in their own feces rather than be moved secondary to pain. Lying in poop with pneumonia in severe pain unable to be moved is no way to die. According to the data we have nonoperative treatment would have given her zero chance to see him elected.

Even with special beds and wheelchairs, you still have to at minimum be able to tolerate a transfer. An acute care wing at most hospitals have all of those resources and tons more manpower and it is an issue with them. Hospice will more than likely be completely undermanned.

I've had several patients in hospice who have had hip replacements. Obama's GM may well have been in hospice. Hospice doesn't mean that problems are not treated. The thought of lying in bed with a broken hip for the final weeks of your life is just horrible. It would be a very short period, mostly "terminal sedation".

BDS, LindaB and J Bean--thank you for your educational, consciousness-raising comments! (and thnx to Ezra for posting on this topic)

These issues of EOL Care and QOL have always been with us but will greatly increase due to the aging of the US population.

With implementation of meaningful nat'l hc reform in the next year or two (with a solid Medicare-for-All public insurance option) we have the potential to make great strides in improving care in this area.

EOL care is just one of the areas that beg for guidelines to support greater clinical effectiveness, and consistent delivery of high quality compassionate care.

Relatively new to the public realm there's a national project on EOL care started by the sister of a woman who died of cancer in middle age. It's called
Engage With Grace: The One Slide Project"

http://www.engagewithgrace.org

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