ShareThisDying can be expensive. Studies show up to a third of all money spent on Medicare patients each year goes toward the 5 percent of elderly and disabled enrollees who die.
Dying well can also be expensive, but usually less so if patients, their families and their doctor have honest conversations about end of life care.
A new study published this week in the Archives of Internal Medicine looked at the experience of 600 patients with advanced cancer to see whether they had talked with their doctor about how care should be managed as they approached death.
The cost of care for those who did not have such a discussion was 36 percent higher -- an average of more than $1,000.
"We refer to the end-of-life discussion as the multimillion-dollar conversation, because it is associated with shifting costs away from expensive, burdensome, non-curative care, like being on a ventilator in an ICU, to less costly comfort care provided at home or in hospice, which most patients and their families say they would prefer," said Holly Prigerson, a researcher at the Dana Farber Cancer Institute in Boston and the senior author of the study.
The notion of a "good death" -- being able to spend your last days at home or in a nursing home or hospital, on your own terms, free of pain and chaotic, futile attempts to extend life -- has been evolving for more than four decades.
Hospice care -- now more likely to be provided at home than in an institution -- is the main model of a team-oriented approach to caring for someone with a life-limiting illness through expert medical care, pain management, personally tailored counseling and spiritual support, and related services for the patient's loved ones.
But more than a few hospitals and nursing homes have been borrowing from the hospice model to provide palliative care -- a combination of pain management and spiritual and emotional support -- to patients who are gravely ill, but who may recover.
Many physicians still find it hard to recommend hospice, since it requires everyone to agree to stop treatment toward a cure. Trained to heal, doctors don't like to admit they can't do anything more to save a patient. And predicting how long a patient has to live is a particularly inexact science that seemingly grows more ambiguous with each medical advance.
The Medicare hospice program, which pays for more than 80 percent of all formal end-of-life care, has been a particular concern to administrators in recent years. Costs have tripled, to more than $10 billion a year, just between 2000 and 2007, with nearly 4,000 Medicare-certified providers.
The hospice benefit is supposed to start when a physician determines a patient has six months, or less, to live, although services can be extended, 60 days at a time, as long as a hospice doctor continues to certify that death is likely within six months.
For more than a decade, various government investigators and analysts have noted that the average length of stay in Medicare hospice keeps getting longer, leading some reformers to suggest that hospices be paid less for longer stays, among other changes.
The hospice approach was initially designed mostly for patients with terminal cancer, for whom the outlook was reasonably certain. Now, only about 40 percent of Medicare hospice patients have cancer, with neurological diseases like Alzheimer's, heart failure or other conditions with less certain courses making up the majority.
More than 1 million people are enrolled in Medicare hospice each year, yet Medicare says only about 40 percent of more than 2 million patients who die each year are in hospice when they pass away.
It's not clear how many more Medicare patients receive palliative care in a hospital or other setting outside of hospice, however, since many of those services are covered through regular payments.
It is apparent that even when doctors recommend a patient to hospice, they need to stay in touch. Another study in this week's Archives of Internal Medicine that looked at the concerns of cancer patients and their families found that many feel a sense of abandonment if they opt for hospice care and the oncologist stops checking in.
"Doctors often don't realize how important this issue is for patients and their families," said Dr. Anthony Back of the Seattle Cancer Care Alliance. "Something as simple as a phone call can go a long way toward allaying abandonment concerns."
At the same time, both the doctor and the patient's family often report feeling a lack of closure or unfinished business if they don't communicate when the patient is near death or soon afterward.
On the Net: http://archinte.ama-assn.org/
Nhpco.org
(Reach Lee Bowman at bowmanl(at)shns.com
The Medical Journal
