Simple Cures?

The Dartmouth Institute for Health Policy and Clinical Practice has been tracking the quality and efficiency of healthcare throughout the United States on a region-by-region basis. The studies track effectiveness against cost. One of the most targeted areas of review – and one of the most sensitive – is the accelerating cost of treating the elderly, particularly in the last two years of their lives. Americans seem to be focused on testing and cure and less on what is called “comfort care” – a decision to make life as comfortable as possible as the end is in sight… not to add physical time to life at the expense of painful and prolonged treatments with little if any enhancement to the quality of life.

This is a tough decision for most people. More time and less comfort, maybe even a lot of discomfort or less time with more comfort and less pain. The initial decision should be made by each one of us well ahead of treatment options; the patients can always change their minds. Often, when the ability to decide is clouded by age or treatment side effects, decisions are left to family members who usually opt to prolong life, even as they watch their relative squirm in obvious discomfort.

I remember my father’s feeble voice asking me to kill him as he writhed in fit of boring agony in a sea of utter uselessness. Comfort care was the right choice, but his hands could not sign the required documents, his once-brilliant mind was no longer capable of understanding. It was my choice; I wish that it had not been. He died of his own accord, of course, as comfortable as his physicians could make him.

Forcing patients to express a preference on how they want such treatment to proceed may be one of the most fundamental methods to reduce healthcare costs as we address national priorities. It also creates an easier path for relatives who want to make the right decision. Deciding to let someone die is really, really hard. Sometimes religious beliefs of one family member are imposed on a dying parent or grandparent who might not even share those views.

Dartmouth results (as reported in the June 11^th Washington Post) show that in larger cities with more specialists, higher costs and more treatment options, the price of the last two years reflects that reality: “In the final two years of a patient's life, for example, they found that Medicare spent an average of $46,412 per beneficiary nationwide, with the typical patient spending 19.6 days in the hospital, including 5.1 in the intensive-care unit. Green Bay [Wisconsin] patients cost $33,334 with 14.1 days in the hospital and just 2.1 days in the ICU, while in Miami and Los Angeles, the average cost of care exceeded $71,000, and total hospitalization was about 28 days with 12 in the ICU.” The June 13^th New York Times hits us with this somber conclusion: “The Dartmouth group estimates that up to 30 percent of Medicare spending is wasted on needless care.”

The Post adds this observation from Jeffrey Thompson, chief executive of Gundersen Lutheran Health System in La Crosse, Wisconsin: “‘At the end of life, what most people want is for their wishes to be respected,’ not to undergo an aggressive battery of tests and treatments.” The point is to encourage people to make the necessary choice in advance. I understand this reality at a level that I still find difficult to communicate. The tears still flow from time to time.

I’m Peter Dekom, and no one said these healthcare decisions are easy.