Reform Health Care Now: End-of-life costs are too high
Filed under: Columns, Healthcare
By the time my father-in-law passed away last September, my wife and her extended family were relieved that his six months of suffering had ended. Paul's arms and hands were black and blue from numerous IV's, blood draws and various other procedures. His weight had dropped substantially, his olive-toned skin was pale, and he was bed-ridden.
Not one of his multiple medical problems alone was terminal, but the ten different conditions affecting nearly every system of his body, slowly but steadily took their toll. His physicians spent most of their time putting out the latest fire. The best hope was that they would be able to stabilize him and send him back to a nursing home. There was virtually no chance of regaining his ability to function at a high level. Over time, we hoped that he would find the strength to make it home, and there were some signs that this might happen. Then one day, things spiraled in the wrong direction, and the end came relatively quickly and painlessly.
This same scenario is played out again and again: A situation is more or less hopeless but gets dragged out for weeks, months and sometimes years. It seems as though the patient's quality of life takes a backseat to treating the problem at hand. More to the point, most family members don't consider the staggering costs of end-of-life care since Medicare covers many people who end up in this situation. In a report issued in April, Dartmouth researchers found that total Medicare spending in the last two years of life ranges from an average of $53,432 for patients treated at the Mayo Clinic in Minnesota to $93,842 for those at the U.C.L.A. Medical Center in Los Angeles.
What's the alternative? No clear answer has emerged, but almost everyone agrees that we have to figure out how to manage end-of-life care in a more cost-effective way as the baby boomers age. And we need to distinguish between care that prolongs life and care that actually heals the sick. For example, one option for cancer patients when it's clear the disease is terminal is to utilize hospice care.
As a resident on oncology rotations, I remember how I admired my attending physicians for being able to sit down and talk with a family about changing their focus from the next gruesome round of chemotherapy to palliative measures, such as self-administered narcotics, to make the end more comfortable. For patients who were still lucid, we often saw both relief and a dignity in allowing them to control their own care in the end.
As residents, we were used to chasing dropping potassium levels with bags of electrolytes and putting in invasive central arterial lines to keep careful track of vital signs -- all with the goal of keeping the patient alive for one more day. We learned that our best efforts were not going to stop our patients from dying. Ordering the patient a milkshake for lunch instead of another CT scan would at least help her suffering.
One problem is that many elderly people don't make their wishes about end-of-life care explicit. Instead, families often feel obligated to do everything possible to continue the fight to keep their loved one alive if the doctor doesn't suggest a more humane course of action.
Long before we reach our golden years, we have to think about how we want to die. In order to do this, as a society, we need to come to grips with our own mortality. That is obviously easier said than done, and may come more naturally to those of us in the health care profession who have become accustomed to witnessing sickness and death.
For starters, healthy people should sign a living will explaining how they'd like to approach the end of life, and when the time comes, they should talk to their family and doctors about their wishes. Researchers reported in the March issue of the Archives of Internal Medicine that patients with advanced cancer who talked about their end-of-life wishes with their doctors had significantly lower health care costs in the last week of life.
In addition, these doctor-patient conversations resulted in fewer cases of aggressive care. This not only saved money but resulted in "a far more peaceful death for patients."
A well thought-out plan for the end of life may involve what some consider "rationing" care but, at the same time, it may also be better, more humane care. Given the importance of using our health care dollars wisely, this is something that is in all our best interests.
This is the seventh article in a 10-part series, 10 Reasons to Reform Health Care Now: Part 2: 87 million uninsured, and growing
Part 1: Syrocketing costs are choking American businesses
Part 5: Insurance reimbursements make no sense
Why is Oprah going to cable? Hint: It's nothing to get teary about
Kisses from Hershey: Candymaker may court Cadbury with $17 billion bid
D-Day for Harry Reid: Can he wrangle 60 votes for Senate health reform bill?
Reader Comments (Page 1 of 1)
7-03-2009 @ 1:55PM
straightbizman said...
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7-04-2009 @ 2:44PM
Jimmy37 said...
I am flabbergasted at this article. When it comes to healthcare, what are we trying to accomplish? Saving lives at all costs? Deciding who is worthy of saving? Do we use cost/benefit analysis to decide if treatment is "worth it?" Some religions claim life is precious and must be saved regardless. Who is going to pay for these costs?
We have a problem in this country. People don't want to take care of their health, as shown by the increase of obesity. They simply want the health system to pick up the pieces, put them back together, and keep them alive. Healthcare directives? These are advisory documents as hospitals will bow to the wishes of the family, unless someone makes that difficult for them. America is schizophrenic when it comes to end-of-life. They'll pee and moan about the cost of someone else' care, but grab onto anything they can to keep themselves alive. Doctors aren't allowed to prescribe narcotics to the elderly because of addictions. Who cares? These people are dying!
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7-07-2009 @ 3:56PM
bmmg39 said...
It's extremely sad and more than a little frightening that we will soon be looking at older people as a group of beds that can soon be emptied and as a pile of money that could be saved. Sorry, Uncle Chester, we young folks decided that your life isn't worth the resources. You aren't "getting better," so we'll just nudge your toward hospice or doing without treatment (whether you want to go or not) until we have successfully gotten rid of you. What, your ethics tell us we can't do that? Yes, We Can!
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7-21-2009 @ 3:22PM
KAREN said...
I am sick and tired of listening to Republicans make statements that they know in their hearts are lies or at best misrepresentations of the truth. People who have no health insurance coverage cannot get "health care" at the ER. They receive prescriptions they can't afford to fill and referrals to doctors who can't afford to see them because they can't pay for an office visit. The ER will take care of the immediate crisis, but it cannot treat the diabetic who cannot buy her insulin or the heart attack survivors who cannot affort the heart medications to keep them alive. I have watched too many people not have a chance because they didn't have health care insurance to treat the problem while it was still curable or at least treatable. One secretary had coverage, but it didn't cover diagnostics. She had breast cancer under the sore on her breast. She died. A diabetic who didn't know she was diabetic until her kidneys failed. She is on dialysis. That's covered, but only after you lose everything. Dialysis is way more expensive than insulin. A young mom delivered a premature infant who spent months in a neonatal nursery because she didn't have insurance or the means to see a doctor. The cost of the nursery and presumed lifelong care could have paid for hundreds if not thousands of prenatal visits. They are trying to scare people by saying we don't want government between you and your doctor. But, wait, we have the insurance company between us and our doctor. Multiple times just this week we had our insurance company call to tell us to switch from a medication that is finally working to another different, cheaper drug, not a generic. We get letters demanding that we use their formulary of medications, not the ones that through trial and error our doctor has finally found to work. We use generics whenever we can, but they are telling us we need to use the medication they can get cheaper, but that doesn't work the same. (It isn't even a person who calls us. It is a computer.) We are wasteing money and LIVES because we have a FOR PROFIT HEALTH CARE SYSTEM. The focus is on making money. OUR ELECTED OFFICIALS SHOULD HAVE THEIR HEALTH CARE COVERAGE TERMINATED IMMEDIATELY UNTIL ALL OF THEIR CONSTITUENTS HAVE HEALTH CARE COVERAGE GUARANTEED. (Not a promise, actually a done deal. In effect.) Those wealthy elected officials should be banned from buying their own coverage or paying for it out of their bulging bank books until their constituents have the same coverage the Senators and Congressmen enjoy now.
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8-11-2009 @ 2:52AM
ddsharper said...
I agree with jimmy37. We already aborted over 100 million babies, next it is the seniors, then it will be those with chronic illnesses and the developmentally disabled, and then it will be you, because you are black (planned parenthood funded by the government at the tune of 300 mil yearly, sucks out 700,000 million black babies every year; 85% of their agencies are in black neighborhoods because black lives aren't worthy.). The Tuskegee experiments and the recently discovered EZ vaccine administered to black and mexican babies worldwide. All of these things by the government. And the stupid populace says yeah, they are a waste of money. Yet, we spend millions on prisoners who kill, cheat and steal, we keep them alive and give them heart transplants and have checks and balances to make sure they stay healthy. Americans are idiots, narcissists and anyone who agrees with this bull is next. I see it everyday. Doctors are incapable of being judges of who lives or dies. How much less capable a stupid public full of Nazi tendencies?
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8-11-2009 @ 2:10AM
ddsharper said...
Health Care Reform Has Already Passed Folks
it already passed because it was hidden in the stimulus bill or American recovery act. it will go into effect October 1, 2009. Seniors will be targeted. They will be denied care even more than now. Options will be calculated by insurance actuaries for cost effectiveness and projected life span. Doctors that are not meaningful users of the system will be penalized and their actions monitored by the new IT system hooked into Washington. More draconian stuff coming, simply google 'health care reform hidden in stimulus bill' and read for yourself. smart cards, genome project stopping you from getting disability, life or other insurance. it is all out there on their HHS website and genome.org and smart card sites. The media has been complicit in hiding the fact that this thing passed long ago. So has Washington. They are putting everything in place, including their pretty websites. All you commies who went along, you are useful idiots, idealists and liberals and you will be next.
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