22 April 2011

Are End-of-Life costs avoidable?

One interesting comment I have seen come up over and over is the idea that end-of-life costs are the thing that is spiralling out of control and that if we could somehow find a way to curb the costs of futile care, then that would somehow solve the health care inflation crisis. Andrew Sullivan endorsed such an idea the other day, a "Modest Proposal," which is not nearly as radical or amusing as Swift's. And indeed, there is a modicum of sense in the idea.Estimates are that spending in the last six months of a person's life account for 30-50% of their overall health care costs, and that the spending in the last year of a person's life accounts for 25% of overall medicare spending.So -- simple solution, right? cut down on the futile care, and we're good to go.

Only problem -- as a doctor, I sometimes have a hard time telling when someone is in their last DAY of life, let alone last year.

Just recently, I saw a guy with dead gut -- ischemic bowel -- a near-universally fatal diagnosis. we worked really hard on him in the ER, because saving lives is "what we do," but it was with a real sense of futility. It was depressing, actually. However, to my great surprise, the patient survived, after many thousands of dollars in expenses and will make a real recovery. He may never go back to work, but he will probably live many more years with good quality of life.

I have a friend whose mother, in her eighties, went in for a coronary bypass, and sadly suffered a stroke and died. Some might well criticize -- what were they thinking doing a bypass in an octogenarian? But consider, she was hale and active prior to the procedure and looked in advance to be a good candidate. And I have seen many nonagenarians who are ten years out from their CABG with good quality of life.

My point is that while some are lucky (?) enough to contract a terminal illness and expire in a planned manner with a clear line drawn on the extent of the interventions, or lucky (?) enough to die quickly and cheaply, many and perhaps most of us will not know in advance which of the several illness we incur as we age is going to be our terminal illness. If you think you can beat it, if your family and your doctor have reason to think you might be able to pull through, then it is difficult to give up. Even if you have an advanced directive, as Andrew suggested (and I wholly agree), in the absence of an established and accepted terminal diagnosis, most patients and families will be reluctant to invoke it and decline care.

So while we may have some ability to reduce costs in the end of life, the simple fact that we tend to get sick before we die, and nobody knows the hour of their death will make them difficult if not impossible to significantly reduce.

8 comments:

  1. Sigh. Nothing is ever easy.

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  2. Thanks for the read--I enjoyed it. It would be easy to sit in Congress and make this decision without thinking about the full ramifications, right? How would we have cut Ted Kennedy's end-of-life care, since, after all, his illness was terminal? But then again, the human condition is terminal. Like you say so well, we don't want now to be our last.

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  3. I appreciate your compassion. I have a graduate degree, but work underpaid and exploited, for someone from another country. I won't go into that, but I have untreated heart problems I cannot possibly afford to have treated on the pittance I am paid. I am lucky to cover my mortgage with what I am paid, but I am surviving (poorly but surviving), and was hoping to make it to medicare to finally get treated. Unfortunately it now sounds more and more like I will again lose out. And, to my amazement, some of the worse supporters of libertarian schemes (who want to opt out of paying for "obese smokers") and the GOP "say no to the safety net" crowd, seem to be elders with great coverage now and pensions from good paying jobs in the past! Part of the problem is overpaid under regulated business leaders... worshipers of Ayn Rand....take a look... the only jobs seem to be commission based sales, advertising, and marketing. The most popular major is business and marketing. Everything is either labeled business or socialism. Any kind of restraint, especially government is bad. FDR, who created Social Security and regulated business is now vilified. The tiny percentage of people who can afford to fly to Europe for shots of monkey glands seem to control it all... The society today is not the decent society I grew up in. PK ia right, society is sick.

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  4. I am largely in agreement. The ones that bother me most are the demented patients getting valve replacements, CABG and several other procedures. Close behind is the nursing home patient with limited cognitive abilities having minor procedures that will not extend life, but are being done to treat a number or just because they have a something we can treat. Fortunately, that is not very common.

    Where we could provide better care, and save money, is if everyone had frank discussions about end of life care. The default is do everything. Many people really do not want heroics once the have diagnosed with a terminal illness. Often those heroics diminish time left and the quality of those years.

    Steve

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  5. One of the things that struck me immediately about Andrew's proposal was the call for one website that you could go to and do the paperwork quickly and easily.

    Sadly, I don't think such a website can occur in the current legal climate about this issue.

    It seems every State has different standards about not only what the document is called but how it is to be drawn up.

    Just an example,If you have paperwork drawn up in Oregon and travel to Michigan for a vacation and get hurt, Michigan may not accept your paperwork. If they do accept it, your Guardian would have to present it in person for them to accept it. No central database for the Michigan Hospital to reference to find out if you have such paperwork.

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  6. More end-of-life costs would be avoided if more people used advanced care planning and shared their preferences with their loved ones and their physicians. In New York, we also have a Medical Order for Life Sustaining Treatment form that enables anyone who is seriously ill to discuss with their MD what interventions they do or do not want, in various circumstances. Once you complete a MOLST, its instructions are supposed to prevail with EMTs, in the ER, in the nursing home, wherever. Alas, many Americans mistakenly believe death is optional -- and some MDs fail to discourage this notion.

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  7. Another thing that would help with end of life costs is more states with a Right to Die law - I wish this was a Federal law. My mother had Alzheimer's. When she found out, she asked about doctor assisted passing and was told there's no option in my state - there wasn't an option in any state when she still had the faculties to make the choice herself. It would have given her the option to go out with dignity and spared the state and federal gov't (since she was retired and on medicaid) a LOT of money that was shelled out for her basic care, the emergency room/hospital visit when she finally contracted aspiration pneumonia, and the hospice care while she was CTD.

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  8. I saw a doctor a few weeks ago intubate a woman dying of metastatic cancer after she told him she didn't want to be intubated. He called her son and the son said "do everything." He didn't tell the son that she had said "no life support." The doctor was just chickenshit.

    When I called him on it, he said I had to, her son wanted her intubated. I said what about her wishes. He said she was too confused to know what she was saying. I asked him why he asked her then. He had no answer for that one.

    She said no, loud and clear when he asked her and he asked her 3 times. It was one of the most shocking things I've seen lately, that intubation.

    But it was the easiest thing for him to do at the time. Lame ass lazy asshole.

    A big problem is a lot of doctors are too chicken shit to tell patients the truth. Or too lazy too deal with the consequences. Its easier just to keep on doing shit and hope the patient lives til the end of their shift and let someone else deal with the death.

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