Living will can lessen the pain

The Baltimore Sun

Sure, fill out a living will because it might let you and your loved ones avoid heartache and agony at the end of your life. But here's another reason: It'll potentially save your heirs and society tens of thousands of dollars.

Especially in Maryland, which is one of the most expensive places in the country to become terminally ill, according to newly published research.

Only 34 percent of Marylanders have living wills, says Dan Morhaim, a physician and Baltimore County delegate. He and Johns Hopkins public health professor Keshia Pollack just did a survey that he says will be the first study of its kind when they publish.

That means two out of three Maryland adults haven't issued legally binding medical instructions in case they can't make decisions.

Two out of three patients risk being kept alive by well-meaning doctors and family when, in fact, their lives are over.

And two out of three risk triggering enormous financial costs that deliver only miserable dividends.

About a third of all Medicare dollars is spent on the last two years of life, according to The Dartmouth Institute for Health Policy and Clinical Practice. A fourth of those dollars is spent in the last six months.

Worse, Maryland was one of four states where hospital spending on dying patients was more than 30 percent higher than the national average, the Dartmouth Institute found.

Medicare spending in the last two years of life was $94,901 per patient with severe chronic illness at the University of Maryland Medical Center and $85,729 at Johns Hopkins Hospital, according to the Dartmouth study.

More conservative

Those hospitals' inpatient costs were roughly twice those of the Mayo Clinic in Minnesota, considered the gold standard in efficient, end-of-life care. While Hopkins was "substantially more conservative" than other Baltimore teaching hospitals in its use of ultra-expensive intensive care for dying patients, "the risk of dying a high-tech, ICU-associated death" was much higher at the University of Maryland, the study said.

Such disparities aren't driven by medical necessity. At any hospital, they're "more a matter of individual institutional practice than a response to what patients want or need," the institute said scathingly a few years ago. "Simply receiving more health care does not result in better life expectancy."

Hopkins has become more efficient in treating heart and pneumonia patients since the study was done, said spokesman Gary M. Stephenson. Hopkins and the University of Maryland both said their patients may have been more severely ill than those at other hospitals.

OK, but I don't think people go to the Mayo Clinic for a nosebleed.

The point is that entering the next world from Maryland is expensive, and you can drastically reduce the fare with a living will and other hardheaded thinking about how you want to die. Hopkins and the University of Maryland didn't just bill Medicare for their dying patients. They billed the families an average of more than $3,000 in co-payments, according to the study.

If everybody signed papers ordering hospitals not to needlessly prolong their lives, it would save billions, Morhaim says. As a doctor he understandably focuses on the humanitarian aspect. But as a legislator he knows the size of the bill.

With living wills, "you don't end up in these situations where you're spending a great deal of money and effort and resources trying to sustain somebody for a few extra weeks or a few extra months," he said. "There's potentially huge cost savings, but the savings are driven by compassionate care, not to save money."

Everything possible

Cost efficiency and a good death go together. Ninety-four thousand dollars for white-coated technicians to slide needles and knives into your hide for two years sounds like $94,000 too much to me.

"But if it was your loved one you would want to do everything possible," more than one hospital professional has told me.

Not necessarily.

Two years ago my Dad was dying of metastasized intestinal cancer. He was 76. Doctors wanted to attack the tumors with chemo. Best case: He would have lived, puking and emaciated, an extra six months.

No thanks, said the old man. He went straight to hospice care, had a wonderful four months with his family and friends and died in his bed with no intravenous tube within miles. We didn't invoke his living will because he was lucid enough to say what he wanted. But it was there if needed, and his saying "No" to chemo came from the same philosophy. It was one of his greatest gifts: Showing how to approach the Great Spirit with courage and dignity.

A living will should be only part of your end-of-life luggage. Talk to family about how you want to go. Maryland also has newly revised "Instructions on Current Life-Sustaining Treatment Options," which give doctors detailed orders after you've entered a nursing home or been diagnosed with a serious illness.

Both it and Maryland's Living Will are on Attorney General Doug Gansler's Web site. (Google "Maryland living will." The legal term is "advance directive.") Maryland's living will is written into statute, so you don't need a lawyer.

Fill it out. Get ready for the next adventure. Save everybody some money while you're at it.

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