Reform Health Care Now: End-of-life costs are too high

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.

More health dollars were probably spent on my father-in-law at the end of his life than were spent on the rest of his 75 years combined. Despite all that money and effort, he was miserable.

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 1: Syrocketing costs are choking American businesses

Part 2: 87 million uninsured, and growing

Part 3: The economy is making the crisis worse

Part 4: The current system emphasizes quantity over quality

Part 5: Insurance reimbursements make no sense

Part 6: The malpractice liability crisis persists

Part 7: We need to practice preventive medicine

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