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Default medicine

February 2011

Published in the February 2011 issue of Today’s Hospitalist

History is full of examples where an idea developed within one discipline “say, economics” ends up having very beneficial applications in another. Health care, for example.

I found one such portable concept in the Pew Charitable Trusts Retirement Security Project. The “Pew” is a nonprofit organization that applies “a rigorous, analytical approach to improve public policy, inform the public and stimulate civic life.”

To that end, it released a report, “The Automatic 401(k).” The report concluded: “A number of economists have undertaken important research and contributed practical suggestions concerning the actual and potential uses of automatic enrollment and related default arrangements in 401(k) plans.” As an example, the Pew report cites one 2001 study, which found that 35% of one cohort contributed to their company’s 401(k) if they had to sign up for it “but 86% participated if they were automatically enrolled.

The “do everything” default
The Obama administration has taken note of this school of thought and has called for automatic enrollment in employee-sponsored 401(k) programs.

So, if you currently contribute to your 401(k) without coercion, great; you have beaten Obama to the punch. If you don’t, I can only share the best financial/life advice I ever received from an attending “in this case, a neurosurgeon “who used to opine more about how to invest than about how to perform a craniotomy. To paraphrase his words of wisdom: “One must pay taxes and die; one should love one’s mother and fully fund all tax-sheltered investment vehicles.” Couldn’t have said it better myself.

How does this relate to health care? In medicine, we have almost limitless examples in which the default is to “do everything,” unless the patient or the patient’s family “opts out.” Here’s my understanding of the default principle: It is human to let circumstances take over when confronted with difficult or painful decisions. We are paralyzed by difficult choices, and we end up making no decision, which in turn ends up being the default decision.

With end-of-life care, this lack of volition in decision-making often leads to the type of futile care that we are all very familiar with. I submit that we should rethink the way we ask people to make these decisions.

Making DNR the default
For example, much has been written about DNR orders, from our failure to aggressively pursue them in futile cases to our inability to agree on a universal color for a DNR wrist band. What I have not seen debated is the default determination that we are all full code.

My purpose here is not to define categories for default DNR. Most of us would agree, for example, that we would include a patient with terminal stage IV cancer for whom all we can offer is palliative care.

However, many of us would debate whether everyone diagnosed with lung cancer should become DNR, unless stated otherwise. These decisions would have to be federally regulated and, ideally, informed by nonpartisan, diverse experts that would include physicians, religious leaders and ethicists. Just such a blueprint exists in Britain’s National Institute for Health and Clinical Excellence (NICE). (Perhaps our first step should be creating an acronym that sounds just as pleasant, while avoiding one that spells out DEATH PANEL.)

My point is that if we hope to truly rein in health care spending, we must begin to think in these terms. I’m sure we all have a wide range of opinions that we’d have to hammer out. But few of us doubt that our country is in real trouble if health care continues to consume an ever-growing percentage of our GDP. That will very soon come home to roost if we continue to provide futile care to those who have both a very poor quality of life “a subjective but ultimately definable term “and are at the very end of a long life.

The power of opting out
We already have proof that default decision-making in medicine has benefits. In this country, only 38% of licensed drivers are organ donors. Our default, which is pretty absurd when you think about it, is that all our organs go to the grave with the rest of us.

But that’s not the case in many countries. In Spain, for instance, you must opt out of organ donation. The result? An impressive 85% of the population are donors.

So, back to our president. When his grandmother, who was suffering from terminal cancer, fell and broke her hip, he was faced with the tough decision of whether or not to have it repaired.

According to President Obama, “I would have paid out of pocket for that hip replacement, just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model is a very difficult question.”

A very difficult question indeed, but one we as a society have to try to answer. Most of us recognize that our current practice of end-of-life care for the terminally ill provides little benefit and may even diminish the quality of life that remains. I hope that by changing our default practice in medicine, we can help make that decision just a bit easier. All by simply asking people not to decide anything at all.

Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial in Mt. Holly, N.J.