End of Life Care: A Conundrum

From email:

"Why Does End-of-Life Care Cost So Much?‏
$33,382 for one hospital stay. $43,711 for the next. And a final $14,022 for the last three days of life. This is the cost of dying in America ... sick people are paying hundreds of thousands of dollars for “comfort care” at the end of their lives. The expensive scans, tests, and treatments that dying patients receive often provide a false hope, and at the end of it, many are surprised to suddenly learn they will still die. The incentives are skewed ... the high cost of staying alive ... and why the notorious “death panels” may be just what patients need."

Having experienced this first-hand, I'm particularly sensitive to the issues involved here. But I'm not the only one: everyone here at IB has been touched by it in some way. So I've asked each of the co-bloggers for their reactions, and would very much appreciate yours, as well - either in the comments or by email:

Bob: The lady is spot on in her assessment.

Problem is, many of us will say it is time to let a loved one go but too often it turns out more like the movies . . . . "Spare no expense. I don't care what it takes, let him live"

Kelley: Back when I was a Social Worker, I worked in an Adolescent Rehab Hospital. My main case load was the diabetic kids, but the other section of the hospital were for children and adolescents who had had life altering injuries which left them as vegetables.

I had a nurse tell me that she would advise her ER nurses not to work so hard to "save" people from catastrophic injuries as the emotional toll and financial costs were simply too much to bear. I recall a brain injured teenager, male, whose only recourse was a nursing home as he was a vegetable, no brain activity. I agree with this woman: doctors are only paid for doing something, not for doing nothing.

Nate: What bothers me is that $33,382 hospital bill probably only cost the hospital $6000 to deliver care. It’s one thing to profit off death but 400% profit margins these people should be outcast of society not pillars of the community.

Mike: Death with dignity - and palliative care - is the idea behind hospice. Not a bad idea. Maybe we should be thinking how to expand the idea so more people can reach death with dignity.

Notice that in the article linked, the author reports that decisions about her father's end of life care were taken away from the family:

"[T]he doctor we had never met before admitted Terence to an advanced-cancer-care ward at the University of Pennsylvania Hospital. And then an entirely new set of doctors took over"

Doctors the family had never met before - strangers - making medical care decisions about her father, instead of her family. Exactly "taking over." Bennett laments that. IMO well she should.

Follow her thought thru another step. If one prefers not to have strangers making the decisions about medical treatment for you or your family members, how much more might one also prefer not to have strangers making the decisions about your or your family member's death ?

Here's an idea. Pick an age - say, 60. Starting at that age, it shall be illegal for anyone to have medical insurance - public or private, individual or group - regardless of ability to pay. And upon attaining that age, each citizen shall be granted a lifetime stipend of $200,000 to use in any manner whatsoever, but with a strong suggestion that it be set aside for future medical care. Beyond that, for citizens above age 60, no more insurance, no more public subsidies of any kind, no welfare, nothing more for medical care.

Now, does that sound kindlier than "death panels?"

Bob: Sure Mike.

Of course you don't have to worry about getting re-elected. Those weenie's in DC can't even agree on making changes that won't impact anyone 55 or older. No way they would offer up your $200k You Bet Your Life plan.

You can make a similar argument for/against premature babies, those with significant birth defects including severe retardation, CP or any number of conditions.

I have known more than a handful of folks with children that are running up $50 - $100k/yr for "maintenance" and these kids will live for years. Poor quality of life, but alive none the less.

Kelley: And here's another thing. The author lumps all charges, hospital and providers into one number. Nate notes that the care would be a certain number, which may be true if the hospital did the care, but the care was done by each different provider, the radiologist reading the cat scans, the PT providing physical therapy, the Hospitalist providing care and diagnoses, so as to be paid, etc. The only providers that cannot bill are the nurses provided by the hospital for care; the hospital bills a facility fee to cover those costs and nurses are very expensive. If you were to take the overhead expenses of all the providers, taking out the hospital-only costs, you will probably find a much more narrow margin, such that the costs are justifiable.

The point is that once you enter the hospital for a terminal condition, all the staff can do is test, not cure, so one must decide if more tests stating the obvious is worth the cost. As the author pointed out, the last hospitalizations resulted in no treatment, only tests and confirmation diagnoses.

Hank: As previously noted, I'm a big fan of Hospice. BUT: Hospice is a choice - not a requirement. So when will HHS Secretary Shecantbeserious announce a "Hospice Mandate?"

There's no question that EOL care needs to somehow be reined in.

My issue is with the idea of an unelected, unaccountable panel of gummint-appointed bureauweenies making that decision.

Mike: Hank, that's exactly my beef as well.

Bill: Is there a solution to the EOL financial problem? As long as some belief systems preach the sanctity of life at any cost, some people will continue to spend other people’s money indefinitely. A healthy body, a dead mind and an irrational hope…those are the cases that become insanely expensive.

Behind the testing, there’s always another question, “Is it really terminal?”

Sometimes, you just don’t know. I had a relative who had an episode of ventricular fibrillation. According to his doctor, less than one out of twenty VFib patients make it to the hospital alive. Of those, a very small percentage survive without substantial neurological damage. He had virtually none. Five years and a pacemaker later, he’s still alive and practicing law. (There’s a bad joke in there somewhere!) With an initial Glasgow score of 6 (aka TFU), would an “efficient” system have spent the $150K to keep him alive? I doubt it.

[Hat Tip: Joyce Tang]