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End-of-Life Care: Healthcare’s Big Ticket Item

More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).

In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):

Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.

The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.

Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).

We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.

While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.

What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?

I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”

My parents are in their late 70′s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.

My mother said tersely, “I hope I die in Europe.”

My father replied, “Whether you’re old or young, it’s nice to be alive.”

But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?

This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at

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5 Responses to “End-of-Life Care: Healthcare’s Big Ticket Item”

  1. PearlsAndDreams says:

    Eeeks that would scare me.

    My husband would be entered into the terminal illness …and that would be tragic. In acute care, there is the assumption that something CAN and will be done.

    In June, there was the assumption that he was not going to make it. We had the discussion of what was to be done regarding end of life care, how drastic, heroic he wanted the care to go. It was the scariest conversation I’d ever had.

    Don and I had had the conversation many times, so I knew exactly what the answers were. There was no confusion in the conversation, but to realize we were AT that day was frightening. In a place where the assumption is, this is end of life care, I’m not sure the mind set would be ‘he could make it’.

    Am I making sense?

    He did pull through … no one knows how or why. He is now not bedridden (first prognosis) he is not oxygen dependent (next prognosis) although he uses it daily and periodidically throughout the day. He also only uses the walker in the morning, and late in the evening. The cane is only used when he leaves the house.

    Had he not been in a facility where the mindset was ‘we save our patients’ … I am not sure he would have pulled through.

  2. ValJonesMD says:

    Dear Pearls&Dreams,

    Your husband’s case is exactly why I’m opposed to rationing care based on population-based rules. Doctors don’t have a crystal ball, and we shouldn’t be in the business of deciding fates against the will of patients and family. However, we also shouldn’t be in the business of prolonging death or transforming it into an undignified process. It’s a really difficult line to walk, with no way to be sure we get it right every time. Glad your husband had an unexpectedly great outcome.

  3. The Happy Hospitalist says:

    Lets look at it another way.  In the current system of care everyone gets everything all the time.  Unrestricted access all the time.  Regardless of the futility.  Some argue it isn’t futile until the patient is warm and dead. 

    I present it like this.  If we continue to spend insane amounts of money and resources on the patients, who by a concensus of experts on the local level are deemed to be candidates for futile care, then we risk making access to care not affordable for the many more masses who cannot afford insurance.  As health insurance  becomes more expensive, it becomes less accessable to many more.  That managment of one futile care patient to the tune of $200,000, cost the same as yearly insurance for 20 people.  The futility of one created a futility for 20 others. 

    Who is right? And who is wrong. 

    And if you want to insure everyone, you have to have primary care access.  Which means you have to pay your primary care docs enough to survive and to fill the dwindling pipline of students.  Extenders will never be able to take over management of chronic illness, which  are really the users of the system.

    So if you want all care all the time  (FREE=MORE), then you will bankrupt the nation  FREE=NONE. 

    Would you rather ration care?

    Or would you rather make it unaccessable?

    You can’t have both.

  4. ValJonesMD says:

    Dear HappyHospitalist,

    I agree that (due to the physician shortage) a universal coverage system will give everyone equal access to no one. We have a form of covert rationing

    in place now – which is capricious and often unfair. We are absolutely in a crisis, and the only people who can be assured of consistently excellent care are the very wealthy. However, I am personally frightened by the idea that one day the government may create population-based rationing rules that will hamstring physician and patient decision-making. No rule is right every time – and for those outliers, they may be at risk for inappropriate withholding of care and even premature death. That does not sit well with me, though I also agree with you that we have limited resources and must find a way to curb spending. Whatever those solutions are, they must not dictate how doctors practice medicine when lives are on the line. Can you imagine what it’d be like for an ED doc when a trauma comes in: hmm… is this patient over 65? Then just leave him in the corner… under 65? Then we’re doing everything we can to save him – trauma surgery, ICU stay, multiple consultants, the works. That may be an extreme example, but essentially that’s what end-of-life rationing rules would do.

  5. Dr. Scherger says:

    Thanks Val for this courageous Blog.  I agree.  I think as a society we need to return to accepting, even embracing, death as a part of life.  Legend has it that Native Americans would reflect in appropriate circumstances that “Today is a good day to die”.  Death is a part of life, not anti-life.  Managing a death well is part of being a life-giving physician.

    I’ve been doing terminal illness care for 30 years and when a person’s time has come to die (onset of dementia, can no longer care for self, clearly is ready to die), I look for natural opportunities for death, such as a urine infection or a pneumonia (“the old man’s friend). 

    Critical care done futilly is not the only culprit, it is often the simple curative things we do when we shouldn’t that prolongs the misery and suffering.  With moderm curative medicine, we have created with John Fletcher called “Medical Captivity”.  I call it purgatory on earth.

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