Subaqua Sternal Rubs

That's the view of a recent New York Times economic editorial.

So, how can Medicare's ballooning costs be contained? One idea is to let people die earlier.

For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent, said Dr. Gail R. Wilensky, a senior fellow at Project HOPE who previously ran Medicare and Medicaid. Thus end-of-life care hasn't contributed unduly of late to Medicare's problems. But that doesn't mean it shouldn't be part of the solution. "If you take the assumption that you want to go where the money is, it's a reasonable place to look," Dr. Wilensky said.

End-of-life care may also be a useful focus because, in some cases, efforts to prolong life may end up only prolonging suffering. In such cases, reducing pain may be a better use of resources than heroic attempts to save lives.

Some interesting facts from the Center for Advancement of Palliative Care:

• At least 1/3 of all Medicare expenditures go for care of eventually fatal illness.
• 27-30% of total Medicare budget is spent in last year of life.
• Costs per patient-year have increased from $3,488 per person-year (1976) to $13,316 per person-year (1988) in concert with increase in overall costs.
• Of the total amount spent in the last year of life, nearly 40% is spent in the last 30 days of life.

And how effective is this high-technology, end-of-life care? One example is the Left Ventricular Assist Device, which helps a failing heart pump. (But it's not a pump, it's a siphon! [Sorry, my physio professor kinda drilled that into our heads.])

An LVAD implant costs about $60,000 per device, plus an additional $150,000 in hospitalization. Currently, Medicare covers the LVAD only for patients waiting for heart transplants. But it may extend coverage for others as well — which would mean several thousand patients a year would be eligible, bringing the yearly price tag for the implants to half a billion dollars. LVAD is just one of several expensive technologies that would raise America's 1.4-trillion-dollar health care budget even higher.

(to Dr. Tunis): And how effective is the device?

Dr. SEAN TUNIS (Center for Medicare and Medicaid Services): The vast majority of people die within two years, and about half of that time — the people who have the pump — they actually spend hospitalized.

Dr. DIANE MEIER (Mt. Sinai Hospital): Much of the high technology that we use may prolong life by hours to days. But, life in a coma, life dependent on a ventilator with absolutely no hope of leaving the hospital alive and going home — the message to the family is why would they be doing this if they didn't think it was helpful? And yet, the patient doesn't understand that the doctor knows this is futile — but feels helpless to do anything that would stop it.

We don't want to be the bearers of bad news to our patients. We want to be cheerleaders on the side of more life. Patients and families facing serious illness often don't want to discuss the inevitable.

Source: Religion and Ethics Weekly (PBS)

And what is surprising is that with all the money we spend on futile end of life care, most patients don't even want it.

According to a Rand study of hospitalized patients, aged 80 years and older, 70% of patients in the study also reported their quality of life as only "fair" or "poor." [Possibly the same] 70% stated that they did not want life-sustaining measures, only comfort care, and 80% had signed a Do-Not-Resuscitate Order. However, the majority (63%) of the patients received one or more life-sustaining treatments before they died. Fifty-four percent were admitted to intensive or coronary care units, 43% were on a ventilator, 18% received CPR, 18% received tube feeding, 17% underwent surgery, 15% had right heart catheterization, 14% received blood transfusions, and 6% had hemodialysis. Intensive care did not affect survival time.

"It's often hard for patients to refuse treatment, it can be even harder for families, and it's hard for doctors to not treat. But costs keep going up, and sooner or later the government and insurers will have to make some hard decisions." Betty Rollin, PBS Religion and Ethics Weekly

But are these decision the type we want our government to be making, especially with the current administration?

Introducing gatekeepers, the administrators in health maintenance organizations who choose which procedures patients may undergo, could take the often-emotional decisions about end-of-life care out of doctors' and patients' hands. Indeed, incorporating more of these managed-care-style practices into Medicare is a primary emphasis for the Bush administration, along with greater competition among providers, said Bill Pierce, a spokesman for the Department of Health and Human Services.

But Dr. Relman predicted that the public wouldn't stand for it. "That's exactly why the traditional H.M.O., with the gatekeeper, has given way and is so unpopular and has been replaced by the P.P.O." or preferred provider organization, he said.

… Teaching doctors and patients to say no could be a losing battle. "It doesn't fit human nature, and it certainly doesn't fit our culture," Dr. Relman said. "Most Americans - and most people who are educated in advanced societies now - believe that each person is entitled to, technically and scientifically, the best medical care that they can get."

Source: NYTimes

I definitely agree- but where do we draw the line as to what is beneficial, and what is futile?

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