7224 Florin Mall Drive. Sacramento, CA 95823. REFERENCES. 1. Watts MSM: $250,000-Was it worth it? (Editorial). West J Med 1987 Jan;. 146:86. 2. Simonson ...
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Addendum to Living Will TO THE EDITOR: As our population becomes increasingly older, and our ability to keep people alive improves long after quality of life has deteriorated, one ofthe major dilemmas that we encounter is when to withhold life-prolonging treatment. Persons who are mentally competent can participate in the decision. The currently accepted doctrine of self-determination allows us to abide by the patient's wishes with few ethical or legal conflicts. When the person is mentally incompetent and has not specified previously his or her wishes, however, we generally are obligated to apply all reasonable treatment to prolong life. Nursing homes in America are full of patients with Alzheimer's or other types of dementia with no hope of recovery. These persons are unable to participate in treatment decisions. Even if such a person has executed a living will, that document does not prevent interventions including hospital admission, surgical procedures, antibiotic administration, parenteral and gastric feedings for intervening medical and surgical complications and illnesses unless the person can be considered terminally ill. In discussing this situation with my patients, friends and
ADDENDUM TO LIVING WILL OF The following are directions to myv family, my physicians and the health care institutions where 1 may happen to be in the event that I am not able to make valid decisions about my future care. If and when I am no longer mentally competent and there is little or no likelihood that I will regain mental competence
as determined by my physicians, I not onlv requestbut demand that the following instructions for my care be followed: 1. If I am no Iong er able to eat in a normal manner, I do not wish to have mv lRie prolonged by intravenous feedings and fluids, nor nasogastric, nor other gastric feedings. It is my
wish to die if nutrition cannot be provided in the normal manner. 2. In the event of infections, including pneumonia or other serious infections, I do not want parenteral antibiotics or oral antibiotics which in any, way could be interpreted as life-saving. If treatment will make nursing care easier, or if needed to preven-t the spread of contagious infection, then appropriate treatment can be given. Urinary tract infections can be treated only by the oral route; I refuse any pareniteral antibiotics. Topical treatments can be provided Ito inmprove nursing care. wish to reemphasize that when I am no longer mentally coimpetenit, it is my wrish to die in a normal course of events without benefit of medical intervention. If I am at home and can be taken care of there, I do not wish to be taken to a hlospital for specific treatment, except in the case when nursing care is required that cannot be provided at home. If I am in a nursing home and become ill, I do not wish to be transferred to a hospital, the only exception being when it is impossible to provide the nursinig care in the nursing home. Specificallv, I refuse permission to be transferredl to the hospital if the purpose is to prolong my life. D)A'L.
SIGNE)
VVITNESS
Figure 1.-Sample of "Addendum to Living Will" used by author.
several groups of senior citizens, I find that nearly all persons express a desire not to have these life-prolonging measures done for them when permanent dementia or irreversible and progressive mental incompetence becomes their lot. Most persons erroneously believe that by execution of a "living will" they are protected in that situation. To cover nonterminal situations, I have written an addendum to my living will (Figure 1). A number of friends and patients have requested a copy and have executed similar documents for themselves. It is apparent that the American judicial system recognizes and protects the individual's right to determine his or her health care and management. Such a document explicitly defines the person's desires for the future care if mental incompetence intervenes. The family and physicians and other health care providers and institutions are specifically instructed and are therefore protected from legal liability for wrongful death when withholding life-prolonging measures. I believe that all adults should be apprised of this problem and should be offered the opportunity to make an addendum to their own living will. W.A.REYNOLDS,MD Assistant Medical Professor University of Washington, WAMI The Western Montana Clinic 515 West Front St Missoula, MT 59802
Cost-Effectiveness of Fecal Occult Blood Screening TO THE EDITOR: The recent review of fecal occult blood screening (FOBS) by Brendler and TolleI sunmmarizes the current mainstream thoughts on colon cancer screening as supported by the American Cancer Society.2 A closer evaluation of FOBS is warranted because much of the rationale is not well developed. The FOBS is plagued with a low predictive value positive. Though FOBS carries a 1 % to 2 % false positive rate,2.3 the article correctly notes that only about 50 % ofthe positive tests are true positive for neoplasia; of the positives about 10% are cancer and about 40% are polyps. While at first glance this 50% predictive value may appear acceptable, a closer analysis is required because only 5% to 10% of polyps will ever become cancer and then probably at least five years in the future.4 Screening, therefore, actually finds 10% cancer and 2% polyps that will become cancers for a total of 12% lifethreatening lesions. The 1 % to 2% false positive rate thus correlates with a 12% predictive value positive, indicating the vast majority of those screening positive will undergo the extensive, expensive and potentially dangerous workup needlessly. It has been estimated that if FOBS were applied to the entire American population age 45 and above, the ensuing evaluation of all people with positive results would lead to about 3,000 "serious illnesses" (bowel perforation, sepsis and the like) and 100 fatalities annually.5 The majority of these unfortunate people would be free of neoplasia. The article also indicates a lack of sensitivity (that is, a large false negative rate) with FOBS. FOBS misses about 75 % of the polyps and about 25 % of the cancers found by flexible sigmoidoscopy.6 Given that only half of cancers and polyps are within the reach of the sigmoidoscope, the actual
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number missed in the whole colon is approximately twice these numbers. Thus a large portion of people with disease are falsely reassured; indeed the number falsely reassured exceeds the number of true positives. Although FOBS will clearly detect some colorectal cancers and precancerous polyps, it cannot be considered an inexpensive procedure. In fact, one study has shown FOBS to be less than one-twentieth as cost effective as flexible sigmoidoscopy (Anderson JP, Ganiats TG, Kazemi MM: Screening and treatment for colorectal cancer: A benefit-cost/ utility comparison of flexible sigmoidoscopy and fecal occult blood methods using the General Health Policy Model, unpublished data). Unfortunately, enthusiasm for FOBS has not awaited a reevaluation of its cost effectiveness, and over-the-counter FOBS interventions done without medical supervision are likely to muddy the waters further. In this age of cost-containment it is incumbent upon the public and the medical community to reevaluate the cost effectiveness of fecal occult blood screening for colon cancer. THEODORE G. GANIATS, MD Assistant Clinical Professor WILLIAM A. NORCROSS, MD Associate Clinical Professor Division of Family Medicine University of California, San Diego, School of Medicine La Jolla, CA 92093 REFERENCES 1. Brendler SJ, Tolle SW: Fecal occult blood screening and evaluation for a positivetest. WestJ Med 1987; 146:103-105 2. American Cancer Society: Guidelines for the cancer-related checkup: Recommendations and rationale. CA 1980; 30:194-240 3. Eddy DM: Screening for cancer: Theory, analysis and design. Engelwood Cliffs, NJ, Prentice-Hall, 1980 4. Day DW, Morson BC: The adenoma-carcinoma sequence, Chap 6, In Morson BC (Ed): The Pathogenesis of Colorectal Cancer. Philadelphia, WB Saunders Co, 1978, pp 58-71 5. Frank JW: Occult blood screening for colorectal carcinoma: The risks. Am J Prev Med 1985; 1(4):25-32 6. Simon JB: Occult blood screening for colorectal carcinoma: A review. Gastroenterology 1985; 88:820-837
Was It Worth It? TO THE EDITOR: This is in response to your editorial "$250,000-Was It Worth It?" in the January issue.1 In the case report you discuss,2 a habitual intravenous drug abuser survived nine admissions for mitral valve endocarditis, including two valve replacements, accumulating more than one hospital-year out of the past 12 years. Was spending all that money on this loser worth it? Did other people, more deserving ofhealth care, not get it because of him? I wonder how much of your skepticism stems from moral considerations about this patient's worth to society. I have trouble imagining that you would make a similar remark about a case report of a housewife with an exceptional case of systemic lupus, who survives repeated hospital stays and runs up a huge bill that society must pay. I confess that I do not feel entirely sanguine about cases like this either. I pay taxes too, and thank goodness that there are not more patients like this fellow than there are. I believe, however, that we must resist firmly any effort to put us medical doctors in the position of judging who is fit to be treated, and who is condemned to be declared surplus. I have seen scenarios like that in Orwellian science fiction stories. When I am faced with moral dilemmas such as are exemplified by this case, I remember a quotation from Mencken: "The purpose of the medical profession is not to make men
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virtuous. It is to rescue them from the consequences of their vices." I emphasize that I am addressing the idea of whether to decide to treat on the basis of the patient's moral worth. I do not advocate futile treatment that needlessly prolongs suffering. RICHARD M. COHEN, MD Fong Diagnostic Laboratory 7224 Florin Mall Drive Sacramento, CA 95823 REFERENCES
1. Watts MSM: $250,000-Was it worth it? (Editorial). West J Med 1987 Jan; 146:86 2. Simonson J, Schaaf VM, Mills J: Nine episodes of infective endocarditis in one patient-A new record. West J Med 1987 Jan; 146:96-98 *
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TO THE EDITOR: I read your editorial in the January 1987 issue: '$250,000.00-Was It Worth It?"" I do not believe it was worth it. An individual has a right to do anything to his body he cares to do. However, when a physical abuse that is self-inflicted becomes a financial burden on me (society), then that right ceases. We all know that in all aspects of our lives we can do anything we care to do as long as we do not violate the rights of others. When a person abuses his body, that is his right. When he abuses it to the point of seeking health care and I am financially responsible, then he violates my rights. The answer to your question-"Was It Worth It?"-is no. In instances of physical abuse that is self-inflicted where there is no financial responsibility, the individual person seeking treatment should simply be given a comfortable place in the hospital where the person is maintained, and if he survives, he survives. If he does not, he does not. This would save vast sums of money spent on a hopeless problem, allowing the expenditure of the same money in needed areas. For those who are financially responsible-for instance, with medical insurance-there should be surcharges to cover the added costs incurred by their physical self-abuse. I note that some insurance companies are already headed in that direction, giving discounts for nonsmokers and nondrinkers. The problems of physical self-abuse will always be with us. The financial responsibility for that abuse should be placed squarely on the person abusing himself. Just possibly not spending the money on those who do abuse themselves would reduce their numbers so that others who really need health care would have funds available. GLENN W. DRUMHELLER, DO 1515 Pacific Avenue Everett, WA 98201 REFERENCE
1. Watts MSM: $250,000-Was it worth it? (Editorial). West J Med 1987 Jan; 146:86
Natural Death Acts TO THE EDITOR: I am writing regarding the Commentary "Nora's 'Living Will' " by Dr E.R.W. Fox in the January issue.' It was sensational! We here in the state of Washington are wrestling with revisions of a "natural death act" that, we hope, ought to be adopted this year. Moreover, the Washington State Medical Association has agreed to "push" discussion time about living wills and death and dying with patients so that the issue
