The high cost of dying

Why are we using so many health care resources on dying patients?

Although the Affordable Care Act should be applauded for increasing access to care, assisting small businesses with coverage and emphasizing preventive care, it falls short on cost containment, with health care costs still rising along with spending per individual case. And while it has provisions in place to fight fraud, it's not expected to make much of a dent in the $750 billion — or 30 percent of total health care spending — that the Institute of Medicine suggests is wasted annually on unnecessary services and excessive administrative fees.

Much of that "waste" may be attributed to aggressive care during the last year of life.

According to the Centers for Medicare and Medicaid Services, a quarter of Medicare spending is reserved for the 5 percent of beneficiaries who die each year. Using 30 years of Medicare data, researcher Gerald Riley showed a steady temporal increase in the number of repeat hospitalizations during a Medicare beneficiary's final year of life. Many patients die in the intensive care unit (ICU) — among the costliest types of hospitalization — and there is a trend toward more hospitalized patients dying in the ICU, according to a study by Brown University researcher Joan Teno, who published her work in the Journal of the American Medical Association.

As an ICU physician, I have seen that modern intensive care medicine can contribute to miraculous outcomes. ICUs now provide temporary artificial liver support, prolonged artificial circulation and perioperative care for solid organ transplantations of all kinds. However, my experiences in several major medical centers have also shown me that there is a problem with ICU spending in patients that are highly likely to die in the hospital.

There are a number of possible underpinnings to this problem. American medical schools teach students to treat disease above all else; there is little to no emphasis on end of life care, particularly in the ICU. Likewise there is no basic education in health economics or policy. Instead most physicians simply learn "on the job" about these issues, which is suboptimal.

Several policy initiatives could help to address these issues.

First, the American Council on Graduate Medical Education should mandate that medical schools include education about end of life issues. Alternatively, state medical boards could mandate graduate medical education pertaining to the topic. Mandatory topics should include enhanced communication, terminal pain management, advanced directives and economics of end of life care.

Hospitals should also pilot programs that have mandatory case review for patients who remain in the ICU longer than 30 days. The purpose of these reviews would not be to advocate for termination of supportive care, but instead to provide a regular forum for discussing the patient's condition with the patient's primary physician, intensive care physician, palliative care physician and other stakeholders. Formalization of the process would help to ensure that a patient's advanced directives are being followed and that physicians with different backgrounds and stakes communicate effectively.

Finally, physicians need enhanced education about how the legal system will treat them if they refuse to provide futile care. There is a perception among physicians that they must provide all care that is requested by a patient's family regardless of the probability of success. In fact, the AMA code of ethics states that physicians have an obligation to transition patients to palliative care when treatments have no reasonable chance of benefit. Also, some states (Texas, for example) have statutes protecting physicians from civil and criminal prosecution when they refuse to provide futile treatment. Other states should consider similar laws.

Curtailing the cost of dying in the ICU is a difficult subject, but it is inevitable if the United States plans to control health care spending.

Dr. Michael Mazzeffi (mmazzeffi@anes.umm.edu) is an assistant professor of anesthesiology at the University of Maryland School of Medicine; the views expressed her are his own and not affiliated with the university.

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