Correction: Most newly graduating and practicing doctors. Established doctors make good money, the lowest average being around 150k year. I don't feel for doctors in general because they are making tons of money off the backs of sick patients. It's time to end for-profit medicine and move to a sane single-payer system. The only thing stopping this is the love of money. Things should be like the military or government, where the medical schools are run by the government and doctors graduate with no debt, but are required to give the government 10 years of service in lieu of tuition. They would get promoted based on time in grade and time in service. They would receive sane salaries like military doctors. It's beyond time to remove the incentive of money for good treatment.
Just like bakers, farmers and chefs. They make money off the backs of HUNGRY people. It's time to end for-profit food-making and move to a sane single-payer system. Things should be like the military or government, and they would receive salaries. It's beyond time to remove the incentive of money for good treatment.
At least helicopter daddy and blackhawk mommy give a shit about the Precious. Or do you prefer the absent daddy and welfare mommy? People DO go overboard... but I feel like the pendulum is starting to swing entirely too far the other way.
I AM a physician, and yes, whoever does the demonstration takes quite a bit away from the demonstration by being pretty horrific at suturing... like 2nd year medical student who hasn't practiced bad. If they are going to compare quality of tissue approximation between sutures and their glue, they should probably use proper technique. A plastic surgeon would have laid out 10 sutures or more into the same space, probably in half the time. I am sure there's a senior surgery resident out there who wouldn't mind getting a few hundred bucks to tie a few sutures on camera.
That being said, there are some structures in the body that are very fragile, and difficult to sew. Also, the elderly and the chronically ill have tissues that just fall apart, limiting the usefulness of many surgeries in managing their illness. If we could create seams that don't rely as much on tissue strength, we could probably operate on quite a few more people.
I once attended a seminar by one of the heads of emergency response from the city that's often portrayed as the world's biggest terrorism target. He was going on about communications equipment that is stored away for use after a low-yield nuke detonation. I asked the speaker whether the equipment and storage facilities are shielded against EMP. He asked me what "EMP" is.
There have been plenty of people who argued for banning the use of cash. In many EU countries I believe they already have a ban on cash transactions above 1000 euro.
You don't live in that kind of a society right up until the moment when you do live in that kind of a society, at which point it is rather too late to do anything to prevent it. Trust someone who lived behind the iron curtain - you don't WANT to know what society will be like if we keep heading in that direction. However small those steps are, they are not reversible.
Actually, it's worse than that. What will undoubtedly affect most people is not the power imbalance between the individual and the government as a whole, but the tremendous power imbalance between an individual and the lowest tier public worker that has access to that information. When your local policeman will be browsing your daughter's naked photos (that she took in the shower with her cell phone) while contemplating which would be better to coerce her into sex, her confession about cheating in French class, smoking a joint once a year ago, or going on a date with two different people without them knowing it; and when you find out, and the same person will threaten you with being arrested for anything he could make up he saw in the surveillance, put you on a watch list, destroy your life.... that's when you will realize how far the power separation has gone.
Take it from someone who was brought up in the Soviet Union - even the lowliest civil servant had power, and exercised it. There was no action without bribery, and there was not even a concept of freedom... not because of power coming from the top down, but because the system was so skewed at a traffic cop could pull you over, rob you, rape your wife, then kill you both, and if anyone witnessed it, they'd keep their mouth shut.
Power corrupts.
If you give someone absolute access to your information (even forgetting the concept that the latter will likely mean absolute access to making stuff up), you given them absolute power over you.
Well, if we didn't have to document several fold more, and got paid less for interacting with patients, we may do it. As it stands, unless a doctor is doing something to you, he/she is unlikely to get paid much. Obviously there are upsides and downsides to a system that rewards cutting but not measuring.
Why would it need to be sterilized? It's on a person's face, probably the dirtiest place in the OR. Or are you suggesting that we autoclave all the other surgeons' premium eyewear?
The disposable plastic face shield goes in front of the dirty bacteria-ridden face, glasses or not.
Information imbalance creates a vast power imbalance. And we'd be fools to think that this power imbalance would not be exploited. Generally, in military terms you talk about capabilities, rather than intentions when making assessments. So when universal surveillance becomes a capability, we have to assume it's not just used, but used universally. And one doesn't have to go far in history to search for consequences of having such a system. While not nearly as sophisticated, East Germany during the Soviet era provides plenty of evidence for what WILL be done with the information obtained as a result of a vast surveillance network. In a few words, mainly ammunition for the government to persecute and discredit critics (which isn't new), but also alarmingly but unsurprisingly, a way for those with access to this information (specific individuals within law enforcement and government) to exert this power over other private individuals for spite, profit, blackmail, coverup, etc. It's happened before. We have to be fools to think it won't happen again.
Yes, the reform is in the direction of no-privacy for everyone.
I have to say it, but we should mod up the AC.
The active privacy reform across the industrial world (yes, EU, UK, AU I'm talking to you as well, not just US) is the assertions that: 1. there no right to privacy for the citizens 2. there IS a right to privacy for n, where n=power or money (read: police, government, corporate interests) 3. noting a vast power unbalance as a result of 1 and 2 makes one a terrorist
And that is fairly scary for hospice situations. If people are not allowed to die, eventually they will gain tolerance to the painkillers and there will be some suffering, and there is not a thing they can do about it.
Intent is the key. If your goal is to control pain at any cost in a terminal patient, and the next dose of opiate happens to stop them from breathing, that's fine. But I am not going to give them a dose of opiates that's INTENDED to stop them from breathing. It's a fine line, but an important one.
Because I swore to do no harm. I am not sure that it's a good precedent for doctors to do that. I recognize the source of the contention, and I even sympathize. I'm just not sure that I can foresee a way to make the negative implications less scary.
Step 1. Most importantly, TALK TO YOUR LOVED ONES. If they don't know your wishes, they will be unable to interpret them if that time comes. Step 2. Fill out a healthcare proxy form, available from any primary care MD or even the state itself, with preferably a hierarchy of surrogate decisionmakers (in case of an accident involving more than one person). Step 3. Discuss your wishes with your doctor and lawyer, who can help you iron out the language for a living will.
Consider though that 1 and 2 are much more important, because unless you specifically prohibit something in your living will, your proxy or surrogate may overrule it on your behalf. However, I would discourage you from writing any absolutes in your living will. It's not instructions, it a reminder and guidance for your healthcare proxy. Otherwise, you may miss a potential live-saving treatment that was unknown to you or unavailable when you filled out the form.
When it get to the point where even the most powerful pain meds are no longer very effective, agony and torture are properly descriptive.
There is no such point. Opiates have no ceiling effect. In terminal patients, unless it is was prohibited by the patient, or the surrogate disagrees, it is appropriate to escalate opiate dosing to any level required to achieve pain control. What the effects of that dose would be otherwise is irrelevant.
Now that's not always done, sometimes because of family, sometimes because of the doctor's discomfort... which is why it is so important that palliative care education be a large part of medical education in the US.
You don't REALLY need to make those decisions if you trust your healthcare proxy (I hope you all have one) to know what your wishes are. The doctors (if they are good) will talk to them about the available options if such a need arises (I hope it doesn't for you or anyone else).
How ironic that a doctor doesn't want "extraordinary measures". It is like a car mechanic who says "take it to the scrap heap" rather than opting to replace the engine or transmission on his '57 Chevy.
That's a silly comment. Extraordinary measures are fine, as long as they accomplish something. Hence the word "reversible" in my original post. If all "extraordinary measures" (by which I assume you mean enteral feeding, mechanical ventilation, etc) are doing is keeping a shell physically alive, that's not at all equivalent. The equivalent would be keeping a car that's been crushed in a press in your garage for sentimental reasons.
Neither. In the absence of artificial hydration intravenously or via percutaneous or intranasal gastric tube, people who are unable to tolerate PO liquids will pass away rather rapidly. For discussion of pain control in terminally ill patients, see another one of my replies in this thread.
I think you're making a lot of assumptions that are fundamentally false by projecting your imagination into a situation that is very different. People with mental status that is sufficiently compromised to fall under the category I am describing are not really able to feel hunger the way we do. Actually, starvation due to decreased drive to eat is one of the primary mechanisms of end-stage dementia. Also, appropriate end-of-life care within the palliative setting involves very aggressive pain control. At no point should anyone in hospice care die in pain.
For the most part, while there are exceptions, active suicide is almost unnecessary for someone in a grossly debilitated state. As a physician, I both have a living will and my family is well-informed that if I ever lose the ability to function mentally, in a way that is not reversible, I am not to receive ANY life-prolonging treatment. That means no artificial hydration, no feeding, and no antibiotics. Many of my physician colleagues have made similar arrangements. That's why MDs are the group in the population with the lowest end-of-life cost. While a surrogate or healthcare proxy may not make a decision to end a life, they are certainly within their rights to do the abovementioned, unless a person's living will specifically forbids it. In general, this means a person will pass away within days. For the most part it allows the family time to fly in, and make peace with the inevitable.
Creationist is not a system of scientific thought. Neither is "intelligent design". The whole concept of a scientific system is that it makes no assumptions, beyond being able to attain accurate and true measurements. Teaching "intelligent design" is a gross intellectual dishonesty because it IS an excuse to teach religion. Once you "presuppose" a specific world view, you've negated any concept of science.
I have faith, I even believe in God. Yet I'm a scientist, and I think I will utterly fail both faith and science if they are ever allowed to meet in my head. Once is a philosophical framework for the world. One is a structure of strict mathematics and logic. They have nothing to do with one another, and every time someone tries to bulldoze scientific education with their narrow-minded unimaginative worldview that does truly derive solely from a n-thousand-year-old book, it makes me cringe.
If I want to teach my kids religion, I'll do it, or I'll send them to temple, or a religious school. Please don't teach them YOUR version of a specific world view in public school.
Slashdot Mirror
You've got to be kidding me. Almost no drug gets anywhere near that. I'm happy with one log10 of leeway.
Correction: Most newly graduating and practicing doctors. Established doctors make good money, the lowest average being around 150k year. I don't feel for doctors in general because they are making tons of money off the backs of sick patients. It's time to end for-profit medicine and move to a sane single-payer system. The only thing stopping this is the love of money. Things should be like the military or government, where the medical schools are run by the government and doctors graduate with no debt, but are required to give the government 10 years of service in lieu of tuition. They would get promoted based on time in grade and time in service. They would receive sane salaries like military doctors. It's beyond time to remove the incentive of money for good treatment.
Just like bakers, farmers and chefs. They make money off the backs of HUNGRY people. It's time to end for-profit food-making and move to a sane single-payer system. Things should be like the military or government, and they would receive salaries. It's beyond time to remove the incentive of money for good treatment.
See what I did there?
Yeah. GPS road tax... sponsored by the NSA and your local police department that does not track you without a warrant.
At least helicopter daddy and blackhawk mommy give a shit about the Precious. Or do you prefer the absent daddy and welfare mommy? People DO go overboard... but I feel like the pendulum is starting to swing entirely too far the other way.
I AM a physician, and yes, whoever does the demonstration takes quite a bit away from the demonstration by being pretty horrific at suturing... like 2nd year medical student who hasn't practiced bad. If they are going to compare quality of tissue approximation between sutures and their glue, they should probably use proper technique. A plastic surgeon would have laid out 10 sutures or more into the same space, probably in half the time. I am sure there's a senior surgery resident out there who wouldn't mind getting a few hundred bucks to tie a few sutures on camera.
That being said, there are some structures in the body that are very fragile, and difficult to sew. Also, the elderly and the chronically ill have tissues that just fall apart, limiting the usefulness of many surgeries in managing their illness. If we could create seams that don't rely as much on tissue strength, we could probably operate on quite a few more people.
I once attended a seminar by one of the heads of emergency response from the city that's often portrayed as the world's biggest terrorism target. He was going on about communications equipment that is stored away for use after a low-yield nuke detonation. I asked the speaker whether the equipment and storage facilities are shielded against EMP. He asked me what "EMP" is.
I walked out.
There have been plenty of people who argued for banning the use of cash. In many EU countries I believe they already have a ban on cash transactions above 1000 euro.
You don't live in that kind of a society right up until the moment when you do live in that kind of a society, at which point it is rather too late to do anything to prevent it. Trust someone who lived behind the iron curtain - you don't WANT to know what society will be like if we keep heading in that direction. However small those steps are, they are not reversible.
No one seems to think we are on a slippery slope here.
Not anymore. I think we're long past it. We're like Wile E Coyote... we've run off the cliff, just haven't fully realized it yet.
Actually, it's worse than that. What will undoubtedly affect most people is not the power imbalance between the individual and the government as a whole, but the tremendous power imbalance between an individual and the lowest tier public worker that has access to that information. When your local policeman will be browsing your daughter's naked photos (that she took in the shower with her cell phone) while contemplating which would be better to coerce her into sex, her confession about cheating in French class, smoking a joint once a year ago, or going on a date with two different people without them knowing it; and when you find out, and the same person will threaten you with being arrested for anything he could make up he saw in the surveillance, put you on a watch list, destroy your life.... that's when you will realize how far the power separation has gone.
Take it from someone who was brought up in the Soviet Union - even the lowliest civil servant had power, and exercised it. There was no action without bribery, and there was not even a concept of freedom... not because of power coming from the top down, but because the system was so skewed at a traffic cop could pull you over, rob you, rape your wife, then kill you both, and if anyone witnessed it, they'd keep their mouth shut.
Power corrupts.
If you give someone absolute access to your information (even forgetting the concept that the latter will likely mean absolute access to making stuff up), you given them absolute power over you.
Well, if we didn't have to document several fold more, and got paid less for interacting with patients, we may do it. As it stands, unless a doctor is doing something to you, he/she is unlikely to get paid much. Obviously there are upsides and downsides to a system that rewards cutting but not measuring.
Why would it need to be sterilized? It's on a person's face, probably the dirtiest place in the OR. Or are you suggesting that we autoclave all the other surgeons' premium eyewear?
The disposable plastic face shield goes in front of the dirty bacteria-ridden face, glasses or not.
Information imbalance creates a vast power imbalance. And we'd be fools to think that this power imbalance would not be exploited. Generally, in military terms you talk about capabilities, rather than intentions when making assessments. So when universal surveillance becomes a capability, we have to assume it's not just used, but used universally. And one doesn't have to go far in history to search for consequences of having such a system. While not nearly as sophisticated, East Germany during the Soviet era provides plenty of evidence for what WILL be done with the information obtained as a result of a vast surveillance network. In a few words, mainly ammunition for the government to persecute and discredit critics (which isn't new), but also alarmingly but unsurprisingly, a way for those with access to this information (specific individuals within law enforcement and government) to exert this power over other private individuals for spite, profit, blackmail, coverup, etc. It's happened before. We have to be fools to think it won't happen again.
Yes, the reform is in the direction of no-privacy for everyone.
I have to say it, but we should mod up the AC.
The active privacy reform across the industrial world (yes, EU, UK, AU I'm talking to you as well, not just US) is the assertions that:
1. there no right to privacy for the citizens
2. there IS a right to privacy for n, where n=power or money (read: police, government, corporate interests)
3. noting a vast power unbalance as a result of 1 and 2 makes one a terrorist
And that is fairly scary for hospice situations. If people are not allowed to die, eventually they will gain tolerance to the painkillers and there will be some suffering, and there is not a thing they can do about it.
Give them more opiates?
There's no limit.
Intent is the key. If your goal is to control pain at any cost in a terminal patient, and the next dose of opiate happens to stop them from breathing, that's fine. But I am not going to give them a dose of opiates that's INTENDED to stop them from breathing. It's a fine line, but an important one.
Because I swore to do no harm. I am not sure that it's a good precedent for doctors to do that. I recognize the source of the contention, and I even sympathize. I'm just not sure that I can foresee a way to make the negative implications less scary.
Step 1.
Most importantly, TALK TO YOUR LOVED ONES. If they don't know your wishes, they will be unable to interpret them if that time comes.
Step 2.
Fill out a healthcare proxy form, available from any primary care MD or even the state itself, with preferably a hierarchy of surrogate decisionmakers (in case of an accident involving more than one person).
Step 3.
Discuss your wishes with your doctor and lawyer, who can help you iron out the language for a living will.
Consider though that 1 and 2 are much more important, because unless you specifically prohibit something in your living will, your proxy or surrogate may overrule it on your behalf. However, I would discourage you from writing any absolutes in your living will. It's not instructions, it a reminder and guidance for your healthcare proxy. Otherwise, you may miss a potential live-saving treatment that was unknown to you or unavailable when you filled out the form.
When it get to the point where even the most powerful pain meds are no longer very effective, agony and torture are properly descriptive.
There is no such point. Opiates have no ceiling effect. In terminal patients, unless it is was prohibited by the patient, or the surrogate disagrees, it is appropriate to escalate opiate dosing to any level required to achieve pain control. What the effects of that dose would be otherwise is irrelevant.
Now that's not always done, sometimes because of family, sometimes because of the doctor's discomfort... which is why it is so important that palliative care education be a large part of medical education in the US.
You don't REALLY need to make those decisions if you trust your healthcare proxy (I hope you all have one) to know what your wishes are. The doctors (if they are good) will talk to them about the available options if such a need arises (I hope it doesn't for you or anyone else).
How ironic that a doctor doesn't want "extraordinary measures". It is like a car mechanic who says "take it to the scrap heap" rather than opting to replace the engine or transmission on his '57 Chevy.
That's a silly comment. Extraordinary measures are fine, as long as they accomplish something. Hence the word "reversible" in my original post. If all "extraordinary measures" (by which I assume you mean enteral feeding, mechanical ventilation, etc) are doing is keeping a shell physically alive, that's not at all equivalent.
The equivalent would be keeping a car that's been crushed in a press in your garage for sentimental reasons.
Neither.
In the absence of artificial hydration intravenously or via percutaneous or intranasal gastric tube, people who are unable to tolerate PO liquids will pass away rather rapidly. For discussion of pain control in terminally ill patients, see another one of my replies in this thread.
I think you're making a lot of assumptions that are fundamentally false by projecting your imagination into a situation that is very different.
People with mental status that is sufficiently compromised to fall under the category I am describing are not really able to feel hunger the way we do. Actually, starvation due to decreased drive to eat is one of the primary mechanisms of end-stage dementia.
Also, appropriate end-of-life care within the palliative setting involves very aggressive pain control.
At no point should anyone in hospice care die in pain.
For the most part, while there are exceptions, active suicide is almost unnecessary for someone in a grossly debilitated state. As a physician, I both have a living will and my family is well-informed that if I ever lose the ability to function mentally, in a way that is not reversible, I am not to receive ANY life-prolonging treatment. That means no artificial hydration, no feeding, and no antibiotics. Many of my physician colleagues have made similar arrangements. That's why MDs are the group in the population with the lowest end-of-life cost. While a surrogate or healthcare proxy may not make a decision to end a life, they are certainly within their rights to do the abovementioned, unless a person's living will specifically forbids it. In general, this means a person will pass away within days. For the most part it allows the family time to fly in, and make peace with the inevitable.
Creationist is not a system of scientific thought. Neither is "intelligent design". The whole concept of a scientific system is that it makes no assumptions, beyond being able to attain accurate and true measurements. Teaching "intelligent design" is a gross intellectual dishonesty because it IS an excuse to teach religion. Once you "presuppose" a specific world view, you've negated any concept of science.
I have faith, I even believe in God. Yet I'm a scientist, and I think I will utterly fail both faith and science if they are ever allowed to meet in my head. Once is a philosophical framework for the world. One is a structure of strict mathematics and logic. They have nothing to do with one another, and every time someone tries to bulldoze scientific education with their narrow-minded unimaginative worldview that does truly derive solely from a n-thousand-year-old book, it makes me cringe.
If I want to teach my kids religion, I'll do it, or I'll send them to temple, or a religious school. Please don't teach them YOUR version of a specific world view in public school.