The Smart Money: A frank talk about end of life care

Posted Sunday, March 30, 2014 in Analysis

The Smart Money: A frank talk about end of life care

by Gina Hamilton

Put the bottle on the shelf, children, and come and sit down here. We're going to discuss death, calmly and quietly.

Well, not death, precisely, but the six months or so leading up to death, and the costs of those months.

Death is the natural conclusion to life.  Through the years, there have been plenty of discussions about what we can do to make the dying process less painful and more peaceful. We've established hospice programs and visiting nurses and other things that help us die surrounded by loved ones at home, not hooked up to machines in some impersonal, too-bright ICU where you can't even have a bunch of flowers and your relatives are limited to five-minute visits.

I don't know that we've really solved those issues, but at least a conversation has begun.  We've also been exhorted to consider filling out advance directives, living wills, powers of attorney, and other papers that should keep us from having to make these decisions when the need is staring us in the face.

But this is a discussion of a different kind, a discussion of the costs of the last six months of our lives.

We spend about $2.8 trillion per year on health care every year. Of that, $390 billion is spent on Medicare, and 30 percent of that ... $117 billion annually, is spent on patients in the last six months of life, on about 5 percent of all patients, suffering from multiple organ failure and chronic disease, for whom death is an inevitable outcome, but perhaps not immediately.

Most of these people are elderly, and most don't have advance directives, and most are bewildered by their diagnoses and prognoses and the array of treatments designed to give them another month or two of life that may not even have a high quality.

Now, before we scream "Death Panels", my children, let's think about this from a rational, policy perspective.

Isn't it worth it to have a doctor or counselor discuss advance directives while all patients are still healthy?  The pennies we would spend on such a conversation would save countless hours of anguish on the part of family members, wondering whether Mother would want to live like this, especially if she is unconscious or suffering from dementia. 

Isn't it worth it to establish more and more responsive hospice organizations in every town? We will all face end of life care at some point; the care offered by Hospice is humane, non-invasive, and supportive of both patient and loved ones.  Aren't they as worthy of our medical care dollars as the high-tech life-prolonging gizmos that are automatically offered?

Isn't it worth it to let a patient - not an overly zealous medical team, not even that patient's friends and relatives, no matter how well meaning - decide when enough is enough? And shouldn't he or she have some help when the time comes?

We're not talking about killing people here, or withholding medical treatment against a patient's will. We're talking about some simple realities - that life ends at some point for everyone, and that sometimes, the best possible outcome isn't a couple of months more of pain and suffering.

The average cost of at home hospice care for a Medicare patient, and 83 percent are Medicare patients, is $151 per day. If a person enters a skilled hospice facility, it can be twice that. The average cost to be in the hospital per day is $1,414 in Maine, and if you need specialized care, that cost can zoom into the the high four figures or even five figures very quickly indeed.

In a hospice setting, either at home or in a skilled nursing care facility, the patient is made comfortable, given whatever pain medication is necessary, has a quiet place to receive visitors, and isn't bound by hospital protocol. Are we really going to worry whether Grandma is likely to become addicted to Oxycodon when she's got perhaps a month to live? Are we going to keep her from having her favorite meals because they might contain too much salt?  Are we going to forbid her cat from sleeping with her?  If she wants a glass of wine, shouldn't she be able to have one?  Is there any reason at all why her grandchild shouldn't be in the room solely because of his age, or her son sleep in the chair overnight if she's having a bad day?

When health care stops being about returning a patient back to health and instead becomes about the gentle release of the patient to his or her final sleep, the timbre of the music changes from a bright brass quintet flourish in sharp staccato to a long, slow, sweet viola solo, fading, ultimately, to silence.

The cost of that brass quintet is much higher than the solo viola. The brass is the sound of struggle, but also of hope.  As hope fades, the cost decreases, both in terms of dollars and in the anguish of fighting for life. 

The financial benefit is a much, much lower priority than allowing patients to embrace their destiny in a thoughtful, measured way, removed from the bright white lights and the noise of the modern hospital setting. But as we move toward a more sustainable health care system, the financial benefit cannot be ignored, either.

blog comments powered by Disqus