Some books are more important than others. “Knocking on Heaven’s Door,” by Katy Butler, is such a book. It is a step-by-step account of a journey, a walk through the valley of the shadow of death. It is written with an amazing mixture of lucidity and heart. It is a candle in the darkness that we all face when we cope with the death of our parents, anyone we love— and maybe ourselves.
As a story, it tells of her retired father’s stroke and his slow decline into incapacity, incontinence and dementia, followed by her mother’s death from an exhausted and physically broken heart. It is a detailed story, as personal as it gets, and many readers will find themselves comparing her story with a story of their own. It’s not very long, only 286 pages excluding notes. My bet is that once you start, you won’t put it down.
But why is a personal finance writer suggesting this would be a good book to read? It’s certainly not my usual beat. I can’t say you’ll get rich— or even stay solvent— by reading it.
What it will do is give you better grounding in the biggest, most emotional and least informed issue that we all face as Americans— healthcare. It’s also a “Bet the Country” issue, one that will bankrupt us with, or without, the Affordable Care Act.
In particular, it will introduce you to the enormous expenses and unending indignities that are now built into healthcare in America for older people. It does this by comments throughout the very personal story on how medical decisions are made, how medical expenditures are set, and how the internal logic of our healthcare system routinely leads to tragic and painful results even as it tries to deliver the best curative care possible at all times and all ages. Here’s a sample:
“… the doctors were considering giving my mother coronary artery bypass grafts plus the two valve-replacement surgeries she’d rejected when she had a far better chance of surviving open-heart surgery in decent shape. My mother seems to be heading down the greased chute toward a series of ‘Hail Mary’ surgeries— risky, painful, dangerous, and harrowing, each one increasing the chance that her death, when it came, would take place in intensive care.
“ The cost to Medicare would probably have been in the $80,000 to $150,000 range, with higher payments if things had not gone well. More than a third of Medicare patients have surgery in their last year of life, nearly a tenth have surgery in the last month of life, and a fifth die in intensive care.”
What we now have is “fast medicine”— a medicine that has lost contact with patients and pre-empts vital decisions about the care they receive. Rather than being fully informed about the odds and the full scope of alternatives, patients are quickly made into non-entities and subjected to a long list of procedures that may work on a 40 year old but seldom work on someone who is 80 or 85 years old.
And when there is an attempt to actually pay doctors to discuss all such things rather than immediately suggest a procedure with a known payment, it is hysterically labeled “death panels” and removed so there will be no possibility of better-informed patients.
What Ms. Butler is advocating is called “slow medicine,” a movement coming from Dartmouth Medical School that encourages a more personal doctor/patient relationship and less aggressive care of older people at the end of life. This would be a medicine truly centered on our personal physician, not the specialist of the day whose income largely depends on procedures performed.
Will we ever get “slow medicine”?
Not until we see many more books like this. Not until there are more candles in the darkness. Not until we— all of us— simply insist on it. The doctors won’t lead this. The hospitals won’t lead this. The pharmaceutical companies won’t lead this. The medical equipment companies won’t lead this. The insurance companies won’t lead this.
Need I say that the politicians won’t lead us?
Like anything truly important, this is something where the people need to lead, so our purported leaders must follow.