
                         Roanoke Times
                 Copyright (c) 1995, Landmark Communications, Inc.

DATE: THURSDAY, April 20, 1995                   TAG: 9504200064
SECTION: EDITORIAL                    PAGE: A-12   EDITION: METRO 
SOURCE: CHARLES HITE
DATELINE:                                 LENGTH: Medium

PATIENTS MUST FACE FINAL DECISION

AN APRIL 4 letter to the editor by Mary Therese (``Prolonging life for profits'') makes disturbing accusations about overtreatment of patients in hospitals and nursing homes. She accuses physicians of placing patients on ventilators, dialysis machines and feeding tubes as a way to reap profits from Medicare payments. Hospitals and nursing homes are cast as collaborators in establishing ``Frankensteinian wards'' of dying patients because they need to make up lost revenues from decreasing lengths of patient stays and caps on prices charged for services.

If this scenario were true, it would indeed be frightening. But it's simply wrong to believe that the difficult issue of making decisions about when to end life-sustaining treatment is simply a matter of greedy physicians and health-care institutions trying to make a buck off hopelessly ill patients.

Therese ignores the fact that the vast majority of patients who receive these treatments do reap substantial medical benefits from them. Patients and their families are asking for them. Health-care providers have little economic incentive to foist high-tech, unwanted care on dying patients because overtreatment usually ends up reducing profits. Medicare and other payers of health care don't ``reimburse anything the doctor orders,'' but rather restrict payments through treatment guidelines and price caps.

She asserts that treatment often is given without regard to the patient's quality of life, and seems to suggest that Medicare and other insurers should refuse to pay when quality of life falls below a certain standard. I cannot think of a more Draconian way to make end-of-life treatment decisions. Who among us wants Medicare or any other bureaucracy making decisions about an individual patient's quality of life?

The major cause of end-of-life treatment dilemmas is that most patients aren't able to communicate their preferences when choices must be made about whether to start or continue life-sustaining therapies. Most patients also have failed to discuss their views about what gives their lives value and meaning, and what level of health would fail to meet their expectations for a minimum quality of life.

The past two decades have seen a consensus develop in bioethics and the law that patients or their surrogate decision-makers have the right to make informed decisions, including the right to accept or refuse life-sustaining treatment. When patients fail to communicate their wishes to family members and physicians, dilemmas about whether to withhold or withdraw treatment will persist.

Here, I wholeheartedly agree with a point made by Therese: Advance directives (living wills and durable medical powers of attorney) can help protect patients from treatment they don't want. Information about preserving the individual's right to choose treatment through advance directives is readily available from area hospitals (including Carilion Physician Referral and Health Information) and civic groups (such as the League for Older Americans), as well as from local attorneys.

Charles Hite, of Roanoke, is director of biomedical ethics for the Carilion Health System.

by CNB