End of Life Care – Bankrupting America

It makes no sense to spend the kind of money we do at the last few months of a person’s life when we cannot afford reasonable health care when it can the greatest difference in the quality of life. Stats show us that 10% of the people use 75% of the healthcare dollars in America. A large portion of that is end of life treatments (futile) for elderly people wiht multiple co-morbidities that only extend life by a few weeks or months.

In a world where we all wrote personal checks for our health care, I’d be entirely on board with this. If someone with a terminal illness thinks the best possible use of their accumulated wealth is to blow it on a longshot chance of eking out a few more painful days or weeks in an ICU—and the evidence suggests that aggressive end-of-life intervention often doesn’t even get you that—then that’s their choice. I hope that’s not my own reaction when the time comes. A lot of what passes for indomitable where-there’s-life-there’s-hope optimism in American culture is a not-terribly-convincing attempt to camouflage our failure to come to terms with our own mortality. I hope I’ve made my peace well enough not to insist on every desperate gesture of denial science has to offer. Even if it’s a question of genuinely adding a few extra weeks or months to a long life well-lived, I hope I have enough other worthy uses for whatever money I’ve saved that I don’t empty the accounts buying every last available minute. But hey, death is scary. Maybe I’ll feel differently when the time comes; I certainly won’t second-guess anyone who wants to make a different choice.

Except, that’s not actually how our existing healthcare system works. In the real world, the decision to do throw the kitchen sink at every ailment is either funded by the government, or by private insurance. A fair amount of the time, it will be made not by the actual patient, but by family members for whom “do whatever it takes” is a low-cost salve for the guilt of never actually visiting grandma at the home. The insurers are substantially constrained in the range of treatments they need to cover, which gives doctors little enough incentive to control costs or limit tests or treatments themselves. (My impression is that this is partly a function of an increase in the increasingly cozy relationships between referring doctors and testing facilities.) These “choices” are not free. They are not a noble reflection of the infinite preciousness of life. These socialized costs—and they’re effectively “socialized” whether it’s the government or private insurers picking up the tab—raise premium costs, make it more expensive to employ people, push some people out of coverage entirely, and otherwise divert scarce resources from things that might actually help somebody.  The notion that this perverse result is somehow required by “medical ethics” is simply grotesque.

This is pretty clearly unsustainable. The more medical technology advances, the greater the number of expensive longshots, the more hours and minutes we can lease back from oblivion at ever greater cost. Over the long term, we can decide that any probability of any added increment of lifespan for people in medical care trumps evey other possible private and public good, or we can ration. That rationing can be by individuals weighing the costs and benefits relative to their resources, or it can be by governments—whether directly or by regulation of insurers and providers. Between those options, I’ll leave it to the wonks.  But please, if you’re going to claim an unlimited right to make other people subsidize the understandable impulse for denial and wishful thinking, at least let’s not pretend that it’s somehow a matter of protecting “individual choice.”

From the New York Times Health Blog article – At the End of Life, Denial Comes at a Price

An empty hospital bed.

Like the rest of us, doctors struggle to talk about dying. These conversations with patients occur haltingly, awkwardly and often not at all. But a study published recently in the Archives of Internal Medicine suggests just how costly that silence may be, both in health care dollars and in patients’ suffering.

A team of investigators, led by researchers at the Dana-Farber Cancer Institute in Boston, interviewed 603 patients with advanced cancer. They asked the patients, who had about six months left to live, whether their doctors had discussed their wishes for end-of-life care. The majority — 69 percent — said those conversations had not taken place. And in the last week of life, those patients who had talked with their doctors wound up with medical bills that were on average 36 percent lower — $1,876 compared to $2,917 — than those of patients who did not have end-of-life conversations with their doctors.

Why such a big difference? Dr. Holly Prigerson, a professor of psychiatry at Harvard Medical School and an author of the study, explained that the patients who never talked about their end-of-life wishes were more likely to be resuscitated, intubated or put in intensive care — or all of the above. Patients who had had those conversations generally opted for comfort, or palliative, care at home or in a hospice at much lower cost.

But wouldn’t aggressive, more expensive care at least offer dying patients a bit more time at the end of life? Not according to this study. The patients not only did not live longer overall, but based on reports from family members and other caregivers, they also suffered more physical distress in the end.  

These correlations may not prove a cause-and-effect relationship between end-of-life conversations and outcomes. Still, Dr. Prigerson said, “The study suggests that as costs go up, the misery and suffering index also goes up.”

Why should doctors be so reluctant to talk about dying when patients are terminally ill? Dr. Susan Dale Block, chair of the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute, noted that oncologists don’t want to appear to be giving up on patients by discussing plans for dying. At the same time, family members and loved ones worry that such conversations might upset an already vulnerable patient. And patients themselves often feel their role is to be heroic and to soldier on, against the odds, with yet another treatment or intervention. By Maggie Jones

Julian Sanchez – http://bit.ly/JZzM

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One response to “End of Life Care – Bankrupting America

  1. An uncommonly well-reasoned, thoughtful analysis of a problem to which wingnut conservatives have responded by shouting ‘death panels’ and waving swastikas. This piece is carefully thought out, accurately documented and eloquently stated. Spot on.

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