End-of-Life Care: Treatment Options, Costs, and Difficult Conversations

by julia on July 6, 2009

Making decisions about end-of-life care is tough.

Doing so often requires our acknowledging 1) that someone close to us is going to die, or 2) our discomfort in projecting death in the distant future.

End-of-life care is also a political hot potato: Legislators are reluctant to discuss changing the way that we care for folks during their last six months of life.

They worry that attempts to reform the system will result in a backlash from senior citizens, who make up one of the strongest voting blocs.

But we need to reform end-of-life care for a number of reasons; the single most important being the high cost and low quality of this care.

End-of-life care is expensive: we currently spend a substantial portion of our healthcare dollars on treatments administered in the final year of a person’s life.

Take Medicare, for example.

As the primary insurer of Americans during their last year of life, Medicare provides a good benchmark for looking at end-of-life care spending.

Medicare beneficiaries account for about 70% of all U.S. deaths each year.

While only 5% of Medicare patients die each year, the program spends nearly 30% of its annual budget ($143 billion in 2009) on providing care for this population.

Or, to put it another way, Medicare spends an average of $25,000 per patient in his or her last year of life. This amount seems exorbitant, especially when compared to the $4,000 per year spent on enrollees who do not die.

Spending a lot on a person in her last year of life is warranted, especially if it results in an increased chance of survival.

The hard part is trying to estimate the point at which further treatment simply will not make a difference. We do not want to tell people that they should not have access to treatments that may prove beneficial.

That said, there is evidence that we tend to over treat folks at the end of their lives with little positive benefit.

This is especially true for individuals with chronic conditions like cancer, congestive heart failure and lung disease.

In addition to driving up our total healthcare spending, this practice does not always yield better results for patients, in terms of both health, and happiness, indicators.
Many folks with chronic illnesses would be better served by efforts to manage, rather than treat, their conditions.
Instead, doctors often attempt heroic measures at the end of life that only prolong pain and suffering and that have little chance of success.

How do we know that we are over treating certain patients at their end of lives?

Researchers at the Dartmouth Atlas Project have shown that Medicare spends significantly more in some geographic regions than in others on dying patients.

According to Atlas data from 2006, for example, Medicare spent an average of $23,000 in Miami, Fl, on doctor and hospital care per chronically-ill patient during the last six months of life.

In comparison, Medicare spent just $14,000 per enrollee over the same time period in Portland, Ore.

Why is the bill so much higher for folks in Florida?

During their last six months, terminally-ill patients in Miami saw doctors (mostly specialists) an average of 46 times, and spent more than six days in an intensive care unit (ICU).
They also had a 27% chance of dying in a hospital ICU.
This reflects the likelihood of their being taken to the hospital, as opposed to another less invasive out-patient setting, in the final weeks of life.
During the same time period, chronically-ill patients in Portland saw doctors (mostly primary care physicians) an average of 18 times. They spent one day in an ICU and had a 13% chance of dying in such an in-patient setting.

Interestingly enough, Medicare also tends to spend more on minority patients than on their white counterparts in the last six months of life. Check out our SIDEBAR to find out more.

SIDEBAR: Minority End-of-Life Care Costs

And here’s the kicker:

There is no evidence that the higher volume of care given to folks in high-spending regions actually results in better outcomes for terminally-ill patients.

Many of these folks may even face additional pain and suffering as a result of the invasive treatments and experimental procedures administered that offer little hope of improving their condition.

SIDEBAR: Relationship Between Regional Differences in Spending and the Content, Quality and Outcomes of Care (2009)
	Higher-Spending Regions Compared to Lower-Spending Ones
Health Care Resources	Per capita supply of hospital beds 32% higher. Per capita supply of physicians 31% higher overall: 65% more medical specialists.
Technical Quality	Adherence to evidence-based care guidelines worse.
Health Outcomes	Mortality higher following acute myocardial infarction, hip fracture, and colorectal cancer diagnosis
Physician Perceptions of Quality	More likely to report poor communication among physicians and inadequate continuity with patients. Greater difficulty obtaining inpatient admissions or high-quality specialist referrals.
Patient-Reported Quality of Care	Worse access to care and greater waiting times. No difference in patient-reported satisfaction with ambulatory care. Worse inpatient experiences.