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.
*This blog post was originally published at Movin' Meat*