The way that we care for people at the end-of-life is broken at almost every level, according to a report released last month by the Institute of Medicine, an independent research arm of the National Academy of sciences. The New York Times does a terrific overview of the report . Or you can download all 507 pages prepared by the 21-member, non-partisan panel here.
The report is full of facts and figures and recommendations, but the upshot is this: Our system is geared toward doing more, more, more for patients, even if it’s clear that the end of life is near. Often, the report finds, this “more is better” approach runs contrary to what the patient wants. And, of course, it costs more.
Honestly, none of this surprises me, nor should it surprise the families of my patients: As I do geriatric house calls around the Bay Area, I must constantly counter an elder care system that too often pushes for more treatment rather than smart treatment, that sees the elderly as a collection of ailments rather than as people who have real wishes and preferences, that emphasizes hospital procedures over integrated and coordinated care at home.
The IOM report tries to make some common sense recommendations. Here are a few:
• Medicare and Medicaid should start reimbursing healthcare professionals for talking to their patients about advance healthcare directives.
• Medicare and Medicaid should pay for home health services rather than emphasizing hospital care.
• Low-tech services such as pain management and treatment for depression should have just as much importance as hospital procedures.
• Medical schools should train physicians in effective end-of-life care, and palliative care.
One quote in The New York Times article caught my eye:
“If you meet their needs, treat their pain, treat their depression, get them some help in the house, your costs plummet,” said Dr. Diane E. Meier, a committee member and the director of the Center to Advance Palliative Care. Fewer patients would end up in emergency rooms getting expensive care they do not want, she said, adding, “It’s a rare example in health policy of doing well by doing good.”
And yet, even in the Times article, you can see critics lining up their arguments that doctors are just trying to cut costs, and they’re just trying to deny treatment to patients who want them. I can start to hear the “death panels” cries of the McCain-Palin campaign debate over universal health care.
In my experience, doctors don’t want to deny patients treatment; our problem is that we too often don’t know when it’s time to stop talking of “cure,” and when it’s better to start emphasizing comfort.
Most of my patients are not in a rush to go back to the hospital. Let’s say I’m treating an 89-year-old man with multiple problems: dementia, diabetes, rheumatoid arthritis and hypertension. Let’s say this man has an expected life span of two more years. And let’s say he has a concerning symptom, an irregular heartbeat or something. Does this man want to be taken to the hospital to undergo a battery of invasive tests? Does he want to be exposed to potential infections, poked with needles, surrounded by strangers and bright lights and beeping sounds? Nine times out of ten he does not. But because he has dementia, he cannot say so. And in so many instances, that means that he goes back to the hospital, for more and more treatment.
In my experience, this aggressive treatment toward the end of life often means more misery and an earlier death for patients. Say my theoretical 89-year-old man goes to the hospital for tests. He gets pneumonia from hospital germs, spend weeks in the hospital, loses all his leg strength, gets discharged into a nursing home. Because he can no longer move well, he gets pneumonia again. After a few days, he has to be readmitted to the hospital and he dies there. Yet, if we had done nothing, this patient might have lived another year or two.
In geriatric care, more is not always better. I am heartened that the Institute of Medicine panel recognizes this. But I fear it will take our culture a long time to accept this truth.
What do you think? Do you think Medicare and Medicaid should emphasize home care and advance directives for end-of-life care? Have you or your family member experienced “over-treatment”? Let us know -comment here or on our Facebook page www.facebook.com/elderconsult
Elizabeth (Dr Liz) has over twenty years of experience in providing medical care to the elders. She is board-certified in Internal Medicine, Geriatric Medicine and Palliative Care Medicine. Dr Landsverk founded ElderConsult Geriatric Medicine, a house calls practice, to address the challenging medical and behavioral issues often facing older patients and their families.