The reality is that patients want to have a say in what happens to them when they’re sick and, more often than not, they don’t want heroic and often hugely costly measures to save them. In the new study, researchers found that more than 90 percent of the adults who had living wills requested either limited care or “comfort care” at the end of life. Only 1.9 percent (a total of ten patients out of 3,746) asked for “all care possible.” Aggressive medicine does not equal happy patients. Doctors must acknowledge this and have honest and informative conversations with their patients. In another study, published in 2008, researchers found that end-of-life discussions resulted in less aggressive care-including ventilation and resuscitation-and earlier hospice enrollment, which equaled better quality of life for patients.

Claudia Kalb, on end of life care

andrewromano:

Medical school anatomy chart from Mexico (1857). Available here. 

Daily Romano

All this masculine body-consciousness has some critics concerned. “There’s a lot of evidence that men are starting to be more strongly affected by the cultural discourse in terms of fatness being less tolerated even among men than it was quite recently,” says Paul Campos, a professor of law at the University of Colorado at Boulder and author of The Obesity Myth. “We’re just getting to see the internalization of the self-hatred and the pathologizing of variations of body size among men in ways we’ve always seen among women.” he says. “This culture is so completely f—ked up about it that it’s hard not to have a screwed-up attitude.

Eating disorders: Now for men too!

Here’s Begley, on how depictions of the food portions in paintings of the Last Supper have grown over the millenium:

Over the last 1,000 years, the portions and plates depicted in 52 paintings of the last meal Jesus ate with his apostles have grown bigger and bigger, finds a study to be published in the April issue of The International Journal of Obesity. From dishes to bread to entrees, it’s all been supersized, find marketing professor Brian Wansink of Cornell University and his brother, Craig Wansink, an ordained minister and professor of religious studies at Virginia Wesleyan College.

“We took the 52 most famous paintings of the Last Supper and analyzed the size of the entrees, bread and plates, relative to the average size of the average head in the painting,” said Brian Wansink. Over the last 1,000 years, the entrées have grown 69 percent; plate size, 66 percent; bread size, 23 percent. As art imitates life, he suggests, changes to larger portions and plate sizes “have been reflected in paintings of history’s most famous dinner.”

This video is actually kinda long and boring (apparently, our kids are too fat) but there’s a nice bit from Bill here about his feelings for Starbucks: “I love those raspberry scones better than life.”

About 90 percent of my animal patients are geriatric—and, as odd as this sounds, the veterinary world may hold lessons for the broader health-care system. While pet insurance exists, only roughly 3 percent of owners carry it; even then, clients pay a substantial portion of costs themselves. That means they usually want to know the rationale behind each test. I explain what I think is going on, what I want to look for, and which tests I need to perform to find it. I rank the diagnostics from most to least essential and lay out approximate costs. My clients then choose what they want done, with an understanding of the relative importance, risk, and cost of each option. This step-by-step approach may seem time-consuming, but it dramatically reduces the number of expensive, unnecessary tests. And the process is more gratifying.

Karen Oberthaler, V.M.D., on what vets can teach us about health care

We feel so righteous when we buy organic food or a compact fluorescent bulb or a Prius that our internal moral cup runneth over. According to this model, which is called compensatory ethics, people have an inner sense of how morally virtuous they need to feel to support their self-image. If a few actions (including espousing actions for other people) are enough to justify how we like to think of ourselves, then we do not need to perform any additional virtuous actions. It’s as if we accumulate moral points for ethical actions, and having accumulated “enough” we are free to act amorally, or even immorally. That’s why reminding people of what wonderful humanitarians they are causes them to give less to charity.

Begley, on the ethical pitfalls of green living.

Consider the excitement over cocaine vaccines. Composed of a bacterial protein plus a molecule that is a coke look-alike, they train the immune system to produce antibodies against both. The antibodies also bind to cocaine, preventing it from entering the brain and causing a high. The good news is that the vaccine makes crack less pleasurable, notes Meg Haney of Columbia University, who led a 2010 vaccine study. That suggests the vaccine indeed kept the drug out of the brain. The bad news is that the level of antibodies in the volunteers (55 coke users in a 2009 study, 10 crack users in Haney’s) varied widely. Only 38 percent of the coke users produced enough antibodies to dull the effects of cocaine, and, of those, only half stayed clean more than half the time.

In contrast, a 2008 analysis of 34 studies of behavioral treatments for addiction to cocaine, marijuana, and other drugs showed impressive efficacy. “There is still no generally effective [medication]” for coke, pot, and meth addictions, notes psychiatry professor Kathleen Carroll of Yale University. “But the behavioral therapies we have are quite good,” bringing a 67 percent improvement. Yet that research gets the response of the proverbial tree falling in an empty forest.

Begley, on behavioral vs. drug therapies.

Howard Brody, a family physician at the University of Texas Medical Branch, recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. “I’m pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones,” says Brody. It’s not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.

Medical groups have not exactly beaten a path to Brody’s door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from “we do no unnecessary care” (dermatology) to “only five?!” (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls “nth-line therapy”—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. “I don’t know what n should be,” he says. “But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity.”

Begley, “Medicine We Can Live Without”