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Cost-Effectiveness of Biologics in Early Rheumatoid Arthritis

Axel Finckh, MD, MS; Nick Bansback, MS; and Matthew H. Liang, MD, MPH
[+] Article and Author Information

From Geneva University Hospital, 1205 Geneva, Switzerland; University of British Columbia, St. Paul's Hospital, Vancouver, V6Z 1Y6 British Columbia, Canada; and Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115.


Potential Conflicts of Interest: None disclosed.


Ann Intern Med. 2010;152(5):333-334. doi:10.7326/0003-4819-152-5-201003020-00018
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Aim of management in late stage of Cancer / or a terminally ill Patients is Simply palliative one and not curative and Kins must not be burdened for ICU/ITU anymore, what is practiced by Private Health care Institutions of Kolkata city of West Bengal; Ind
Posted on March 25, 2010
Professor Pranab Kumar Bhttacharya MD(cal) FIc Path(ind)
Institute of Post Graduate Medical Education &Research ,244a AJC Bose Road, Kolkata-20,West Bengal,
Conflict of Interest: None Declared

Unexpected, sudden and very high level expenditure [in Indian rupees of average several few lakhs] and costs are often being incurred on the shoulder of the immediate kins/party of a patient when questions of caring for any patients with a life threatened emergency [cardiac -like AMI, heart failure or any others] or with a terminal cancer patients or a patient in pneumonia or in sepsis, admitted in a private health care hospital ,in their last few days of life, either through transferring the patient in ICU or ITU whether at all needed or not and without consent of patient or his relatives or with an exaggerated explanation of patient condition . It is simply a business approach towards /allienment and never the medical science in name of palliative care. These results continuing rapid rise in treatment costs to be borne by immediate kin/relative of patients, unnecessary and repeated biochemical, radiological, pathological investigations, and many interventions[like ventilator, dual chamber pace maker, angioplasty, drug eluting stenting, MRI, CT even PET or irrational use of costly drugs] in health care system in the mushrooming private health care provider institutions and nursing homes of cities of grater kolkata, in west Bengal state of India. All most all of these private health care institutions/nursing homes and their appointed health care providers, consultants, are today beyond humanistic needs, face and ethics or Hippocratic oath of medical practice and shares often various commissions from drug companies, laboratories/ industries for writing prescription or referring patients, in cash or in kinds. So reform of health care, in this state is highly needed with an improved understanding of the basic concepts of "humanistic needs" and cost-effective palliative care to meet the needs of patients particularly cancer patients. A considerable number of families and its members usually experience severe form of emotional and financial distress and break, when their family member still dies in spite of very high expenditure and it is of course rational/justified to suit a file against health care providers under law of state or country whenever the party feels any negligence, mistake, unnecessary, unreasonable use of drugs or investigations when ever done without consent and scientific explanation and treatment protocol. Here in kolkata ,the health care providers has probably no idea[actually there is no such study here] about the level of emotional distress experienced by the bereaved family members and the perceived necessity for improvement in the care for imminently dying patients and to explore possible causes of distress and alleviating measures. What happens when a close and loved one dies? They are overwhelmed with the shock and bitterness of losing a loved one. But after a while, after the shock starts to wear off, people begin to reminisce about the sweetness that we shared with our loved one. Still later, after the bitterness and sweetness begin to recede, we start analyzing our relationship with our loved one, and come to new understandings.

Thus, we propose that a desirable care concept for imminently dying cancer patients should include relief of patient suffering particularly from pain, family allowance, advisement on how to care for the patient, allowance of enough time for the family to grieve, and ensuring that family members cannot overhear medical staff conversations at the time of the patient's death. I suggest here some important points to follow *Strict avoidance of unnecessary expenses [through unnecessary, unreasonable investigations and interventions like ventilator, or costly medications, antibiotics] and not to put any financial and emotional hardship to patients and their families **to preserve the patient's autonomy at the end of his or her life if any, *** To reduce the financial burden for patients facing inevitable death in any aggressive environment (such as the intensive care unit, where life- sustaining strategies are routinely employed), as well as for their families.

**** understanding what interventions may be reasonable or unreasonable are basic concepts deserving of more attention.

*****Increased health care expenditures are not associated with any survival benefit, and patients whose health care costs are higher will have worse quality of life in their final few weeks of life

Association between conversations which included discussions of life expectancy and whether the patient will or consent availability of morphine to dying cancer patient. Although India is one of the world's leading suppliers of medical opium, many thousands of its citizens experience excruciating pain from cancer every year because they do not have access to the drug. It says that most cancer hospitals, including those that receive direct support from the government to offer cancer care, do not have morphine or doctors are not trained in using it". Many of the cancer patients said that they experiences pain so severe,. so bad that they would prefer to die than live with the pain. Ironically, India is one of the world's biggest producers of opium, the raw material for morphine Some health care provider specialists may tell[I personally know one oncologists to opine. It does not help her pain, but makes her so drowsy that soon she is unable to express the fact she is still in pain and soon afterwards dies. Killed by morphine, but drowsy and still in pain ******palliative sedation and it must be done with informed consent of party : ordinary sedation, proportionate palliative sedation(PPS), and palliative sedation to unconsciousness (PSU). Degree of sedation should match the symptoms proportionality. Palliative sedation are given only to the extent demanded by symptoms. Low demands imply minimal sedation, and higher demands imply greater sedation. With PPS, the level of sedation and the pace of increase are directly related to the severity of otherwise unrelieved suffering. The level of sedation used will be the least amount that can relieve the distress. Although PPS may end with the patient being unresponsive,that is not the intended end point.

Doctors need education to believe in palliative care, especially to understand that death is inevitable. If and when they are convinced, they can talk to the patient and relatives (once it is clear that there are no curative options) and explain that the aim of management is palliative and not curative anymore. Honest communication between clinician, patient and carer and this underpins the rest of the pathway. I am sure the patient will understand and indeed many will be grateful for allowing them to die comfortably, than in pain. Good care is much more than meeting disease specific targets.

Spiritual dimensions of care is very important issues. We don't know nor we understand what happens after death. May be death a portal to new and eternal life for those who believe in an after life. Believe it will be At first, Avoiding costly and futile measures at the end of life is one small way to help save money. End-of-life discussions should have a role in health care reform and deserve their own thoughtful public dialog.

Acknowledgement- To Recently Diseased Late Mr. Bholanath Bhattacharya and Late Mrs Bani Bhattacharya- Diseased parents of Professor Pranab kumar Bhattacharya of 7/51 Purbapalli, Po-Sodepur, 24 Parganas(north), Kolkata-110, West Bengal-India,

Conflict of Interest:

None declared

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