Overtreatment at the End of Life

So why do we over treat terminally ill patients in certain parts of the country?

In general, our healthcare system tends to favor providing more, as opposed to less, care.

There are two main reasons for this:

1. Our fee-for-service payment system provides a financial incentive for doctors and hospitals to prescribe a greater number of tests and procedures than they might otherwise; and
2. We have an overabundance of medical technology that drives utilization. The saying, “If you build it, they will come,” applies here.
3. Click here to read our longer article about these two cost drivers.

Not surprisingly, our overuse of technology, and our over prescription of tests and procedures, continues even into the final years of a person’s life.

But there are two other factors at play here that apply specifically to end-of-life care decisions. 

Talking About Death

For one, most of us would rather not talk about death and dying.

Folks are just not comfortable discussing end-of-life care options, such as where a patient might want to die, and whether a patient would be best cared for in a hospice (rather than ICU) setting.

Having such a conversation means accepting that a friend or family member is going to die.

Further, both doctors and family members often subscribe to the belief that more care is always better, even when a patient’s condition might suggest otherwise. Family members may feel an obligation to try everything, and feel guilt if they don’t.

This excellent article published by the Dallas Morning News includes anecdotes about Baylor University Medical Center’s palliative care team. The team helps patients, their families and their doctors to navigate the difficult conversations about whether or not to continue invasive care. The palliative care professionals also inform and advise folks about different care options that might help to ease the physical pain of dying.

The experiences of Min Patel, one of the palliative care nurses at Baylor, speak volumes. Ms. Patel has found that patients are more willing to discuss their condition realistically, and to request alternatives to care in the ICU, than are doctors and family members.

This may indicate an unwillingness amongst family members to give up, or accept “defeat.”

It is also a reflection of the training that doctors receive in medical school.

Doctors are taught to do everything in their power to save lives. They are not, on the other hand, trained to deal with death.

According to the Institute of Medicine, a 1990’s study of third-year medical students revealed that:

• 41% have never heard a doctor talking to a dying patient; and
• 35 % had never discussed care for dying patients with an attending physician; and
• The majority had never been present when a surgeon told family members that a patient had died.

As a doctor at Baylor explained to residents in a seminar about death:

“We don’t like to fail. We got here by being straight-A students. I think we have a deep-seated psychological need that we live with every day, where we pretend that death is not a part of life – even in medicine, where people die every day.”

A trio of third-year medical students lingered afterward, saying this was their first-ever lecture on death and dying.

Lack of Palliative Care Options

The World Health Organization (WHO) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illnesses, through the prevention and relief of suffering.”

Palliative care:

1. Provides relief from pain and other distressing symptoms;
2. Affirms life and regards dying as a normal process;
3. Intends neither to hasten or postpone death;
4. Integrates the psychological and spiritual aspects of patient care;
5. Offers a support system to help both the patient and family cope with death;
6. Uses a team approach to address the needs of the patient and her family, including bereavement counseling;
7. Is applicable in the early phases of an illness, in conjunction with other therapies that are intended to prolong life.

In short: Palliative care consists of care, but not cure.

Palliative care differs from treatment given an ICU in that it does not attempt to perform heroice measures to save terminally-ill patients.

Palliative care can be administered in a hospital setting. Or patients can choose to receive such care in their homes, or in other out-patient centers.

Palliative care is a relatively new field in mainstream American medicine. It was not until 1993 that hospice care (similar to palliative treatment) was included as a nationally guaranteed benefit under President Clinton’s health care reform proposal.

And as late as 2000, only a few U.S. hospitals provided palliative care services.

Today, more than half of the 50-bed or larger hospitals in the U.S. offer palliative care programs for patients.

• Additionally, the Robert Wood Johnson Foundation now has a Center to Advance Palliative Care.

Some regions of the country are better served than others when it comes to this important care alternative.

• The Midwest and western states have seen the most rapid growth in palliative care programs, while southern and rural regions have lagged behind.
• Palliative care is also more likely to be offered in large non-profit and teaching hospitals.
• Check out this report card to see how your state compares when it comes to palliative care options.

Not surprisingly, Medicare expenditures per enrollee are lower in areas with a greater availability of palliative care options.

Why?

A 2008 study published by the Center to Advance Palliative Care and the National Palliative Care Research Center showed that hospitals can save an average of $300 per day by treating patients in a palliative care setting rather than in an intensive care unit.

• Savings resulted from reductions in pharmacy, laboratory and intensive care costs.
• Said Dr. Diane Meier, director of the Center to Advance Palliative Care: “The potential to reduce the suffering of millions of Americans is enormous. This study proves that better care can go hand in hand with a better bottom line.”

Bottom Line

End-of-life care is an important issue that most of us, as patients, family members, caregivers, taxpayers, voters, and members of society at-large, would rather not discuss.

But there is evidence that we overspend on end-of-life care, and that our loved ones are worse off because of it.

Currently, there are 90 million Americans living with serious illnesses such as cancer, heart disease, diabetes, Parkinson’s, stroke and Alzheimer’s. This number is expected to double over the next 25 years as the baby boomer population ages.

As such, we cannot afford to avoid a serious discussion about reforming end-of-life treatment.

There is reason to be optimistic about the situation.

To date, 84% of medical schools were associated with at least one hospital that has a palliative care program.

• This will hopefully lead to greater discussion about death and palliative care options amongst medical professionals and their students.

And the number of palliative care programs continues to increase. As a society, we should support the expansion and acceptance of this important field.

Finally, we need to have conversations with our families about our own end-of-life care. At the very least, we can complete and file living wills (also known as advance directives) that dictate the kind of care we would like to receive at the end-of-life.

For more information on living wills, click here.

Continue to Page 3 for info on long-term care…