Death with dignity at one-tenth the cost


LAST YEAR, I lost a good friend to cancer. He was 58. When his cancer was diagnosed as incurable, he decided that he would forgo heroic treatment and eventually die at home, in his own bed.

His wife and daughter served as his primary care-givers, seeking to make him as comfortable as possible. His health insurance plan, more flexible than most, allowed for an occasional visiting nurse.

At times, however, when his fever spiked and the nurse was urgently needed, she was hard to reach. The health-care system is not geared up for this manner of dying. Visiting him during one such moment, I figured his wife deserved better than unanswered phone calls. She deserved a medal.

Not only did my friend die with more dignity than people whom **TC have watched expire helplessly, hooked up to futile high-tech contraptions; his manner of dying saved the health system hundreds of thousands of dollars.

A day in a hospital now costs several hundred dollars, just for the bed. Cancer treatment can easily run to $1,000 a day. Six figures is normal for the full course of the disease. A home visit from a registered nurse averages about $60, according to the Visiting Nurses Association.

While many insurance companies now pay for hospice care as an alternative to hospitalization for terminal diseases, few pay for extended home-nursing care. Yet an entitlement to a daily visit from a nurse, as part of a treatment plan, would cost the health system perhaps one-tenth the cost of an extended hospitalization.

Private insurers resist this approach because of belief in the "woodwork effect." An entitlement to nursing care would bring potential claimants, who now suffer in silence, out of the woodwork.

I have another friend, an elderly woman who is rationally contemplating suicide. She is now in her 80s, and has lived a full, rich life. Mentally, she retains all her faculties, though she is beginning to fail physically.

Her concern is that when she becomes more frail, or seriously ill, the choice of whether to end her life will be taken from her. Once she is in the clutches of any sort of institution, dignified suicide will be logistically impossible and institutionally impermissible.

She is also, quite rationally, hesitant even to consult a psychiatrist to discuss her concerns. She is worldly wise enough to know that one does not visit a psychiatrist to obtain advice on whether to commit suicide, much less on how to do it. A psychiatrist would likely pronounce her "depressed," and prescribe medication, or worse, institutionalization.

She is, of course, not depressed at all. As her expected life span draws near its end, she is contemplating her options rationally, with far more realism than the health system.

These dilemmas, and others like them, occur at the crossroads of the ethical, the financial and the political. We would like to think that moral choices about how to die are entirely personal. Unfortunately, they are hopelessly bound up with the fabric of law, policy, regulation, reimbursement.

The choice of whether to pursue heroic treatment in a hospital versus a potentially more dignified terminal illness at home is complicated by the vagaries of health insurance, professional liability, and the deeply ingrained reluctance of the medical profession to permit death to take its course. The issue of suicide is even thornier.

As a nation, we deceive ourselves into thinking that by not having a comprehensive system of health care or coherent policies, we somehow facilitate personal choice. In truth, this form of freedom, as that moral philosopher Janis Joplin once observed, is just another word for nothing left to lose.

Our present non-system permits choices only for those with extremely deep pockets. For the rest of us, our choices are constrained by the arbitrariness and social irrationality of what insurance will pay for. And you can be sure that as costs keep escalating, insurance will pay for less and less.

A comprehensive system -- besides its other virtues of universal coverage and reduced administrative costs -- would force doctors, hospitals, policy makers and the public to look these issues in the eye. It would force the system to come up with defensible criteria, instead of backing into these decisions as the incidental byproducts of scattered cost-containment or liability-avoidance maneuvers.

Surely, a national system would decide that home health care, not just for terminal patients but also as an alternative to expensive nursing-home care, should be far more broadly available. That might also ease the fear of an elderly person contemplating suicide as a way of avoiding institutionalization.

Dilemmas that join questions of medical ethics and public policy are invariably painful, but our failure to have a coherent health systems makes them excruciating.

Robert Kuttner writes regularly on economic matters.

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