Leaving End of Life Care to Docs and Patients

The television show 60 Minutes and Atul Gawande, writing in The New Yorker, have recently weighed in on the topic of end of life care. The message has been that Medicare wastes huge amounts of money on patients in their last two months of life — some 50 billion dollars each year. The further implication of these data is that if only we had a rational, centrally run healthcare system, we could control this great waste of money and time and save Medicare for the future.

Let us deconstruct the economic argument. Medicare spends about 700 billion dollars a year on healthcare for seniors and patients with end stage kidney disease. The 50 billion dollars is clearly a great deal of money but even 60 Minutes claimed that only about 25% could be saved by the use of hospice care and advanced directives (through which patients can spell out their desires for aggressive care before they reach an advanced degree of illness). So what we are talking about here is 25% of 50 billion or 12.5 billion dollars. That would be 1.7% of the Medicare budget.

All the talk about the benefits of rationalizing end of life care amounts to less than 2% of the Medicare budget. Moreover, that 25% savings makes the assumption that we can really tell when the end of life is upon us. How many patients should we consign to “comfort care” where we withdraw active care when there is a 10, 5, or even 1% chance of recovery? Certainly physicians encounter cases where there clearly is futility in continuing care. However, that is not usually apparent at the first moments of a critical illness, even in an elderly individual. We therefore typically start aggressive, expensive care as the outcome is often unclear.

At what age should we no longer pursue aggressive care — 80, 90, 100?  It is usually easy to assess some of these issues when hope is truly gone; but to assess this in the first few days or hours of a critical illness is often impossible. This is why the most we could save is some 25% of the cost of care of patients who die within two months. Much of the time, we simply cannot tell who might respond to treatment.

Moreover, even if we did not adopt aggressive approaches to the care of desperately ill patients or those with lingering terminal illnesses, we would still have to provide compassionate, symptomatic care. This will not be cheap and would require much better coordination of care and settings in which such care could be efficiently provided. Investments in these services would be substantial, although certainly worthwhile.

Finally, many families and patients just want us to do all that is possible. If we do not, we are liable for all sorts of harsh penalties in both the civil and the criminal legal systems. This is another venue where malpractice reform is necessary.

This particular trope of healthcare reform is really the vanguard of other approaches to centrally determine the nature of medical care rather than place those decisions at the heart of the doctor-patient relationship. We currently have these difficult discussions with families and sometimes with patients in intensive care units if they can respond to us. We are not as heartless or as foolish as 60 Minutes implied.

Those who worry about the creation of “death panels” are articulating a legitimate human fear that care will be denied based on an economic consideration. To call them demagogues, as Dr. Gawande did, is the height of condescending rubbish. They want these decisions to not be based on some set of guidelines created by a brilliant committee meeting in the basement of the Department of Health and Human Services. They want them to be based on recommendations made by physicians and communicated to patients and to their families based on unique clinical circumstances.

End of life care deserves careful study and well designed clinical interventions. “Reforming” it will not save much money and should not be held up as a problem to be solved by centralized decision-making.