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Is end-of-life care getting better and worse?

April 30, 2011 Leave a comment

Medicare patients who have severe chronic diseases are becoming less likely to die in a hospital and more likely to receive hospice care, according to a new report from the Dartmouth Atlas of Health Care. This indicates that patients’ preferences for treatment are being honored more frequently — but there are also contradictory findings.

The number of seriously ill patients who see 10 or more doctors during their last six months of life is also increasing, as is the use of specialist MDs, the Dartmouth researchers found. These trends drive up spending, while use of hospice drives costs down.

Data show the same patterns for the Rochester, NY, area (where I live) as for the U.S. as a whole. So the Beatles may be partly right: it could be getting better…and worse…all the time.

Read more…

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The costly American way of dying

April 26, 2011 Leave a comment

The ER doc who posts at “Movin’ Meat” tried to address how expensive it is to die in the US: it’s estimated that 25% of Medicare spending goes to pay for health care services during peoples’ last year of life, even though the outcome is death.

So — simple solution, right? cut down on the futile care, and we’re good to go. Only problem — as a doctor, I sometimes have a hard time telling when someone is in their last DAY of life, let alone last year.

Nobody knows the hour of their death, he writes, and who could disagree? The real issue here is the dramatic under-use of advance care planning, and the reluctance of families to fulfill their loved one’s stated preferences for what medical treatments they do or do not want.

Consider what happens when families actually do what the patient wants, even when that means declining surgery or some other aggressive treatment: the example of Mike Mikula’s father, as reported on cnn.com:

Dad was adamant: “Do not cut me.” He was unwilling to take the considerable chance of stroking out on the table and spending the rest of his life incapacitated and unaware. “I want to go home.” His voice was stern and strong. “I want hospice, and I don’t want to be in pain anymore.”

Mikula’s account of the advance of his dad’s terminal illness does not sugar-coat what happened, especially during the final days, even with the assistance of skilled hospice caregivers. It wasn’t all ‘skittles and beer,’ he declares. He also recognizes how fortunate his family was: both elderly parents knew and said what they wanted, and he and his siblings respected those wishes.

Some doctors indulge themselves and their patients into thinking that over an endless timeline, with unlimited finances, humanity’s losing streak against death can be snapped. But every gambler knows the house always wins. Lots of luck went into my Dad’s “good death,” but luck favors the prepared.

Bill Sez: I hope shadowfax at Movin’ Meat and every other doctor reads and takes to heart the Mikula family story — not only because it will reduce the amount Medicare spends on futile care, but also because it establishes that families are capable of positive, life-affirming experiences even when the outcome is death.

‘I would not get a policy,’ says Aetna CEO

April 8, 2011 1 comment

At a time when Republicans seem eager to destroy Medicare and push older Americans into the individual insurance market, there is one insurance company CEO who knows first-hand what a terrible idea this is.

“I would not get a policy given my personal medical history,” Aetna CEO Mark Bertolini told Kaiser Health News. “I have one kidney. I have a broken neck from an extreme skiing accident. Given the experience with my son and myself, I’m uniquely prepared to see how to fix this system. I’ve watched it work from the inside.”

Bertolini’s son was diagnosed with a rare form of cancer as a teenager, was enrolled in hospice but survived, then received a kidney transplant from his father. Those experiences influenced Bertolini to ease Aetna’s rules about hospice enrollment, and it leaves him repulsed by the “death panels” argument used by Republicans to oppose the Affordable Care Act.

A real big flash point comes up with end-of-life care. Politicians will say ‘death squads: they’re going to put you in front of a committee and decide you’re going to die’. That’s just wrong, it’s not even remotely close. It doesn’t matter what side of the aisle you’re on, someone takes an issue that is good policy and turns it into a political dogfight that creates a dialogue that’s not helpful.

Bill Sez: It’s remarkable how much a powerful guy’s policy preferences are shaped by his family’s experiences with life-threatening illness and injury. This interview deserves much broader attention than it’s likely to receive.

As life ends, preparing for death will challenge you

April 4, 2011 Leave a comment

Americans provide billions of dollars’ worth of unpaid caregiving each year, tending to spouses or parents or other loved ones who are dying or seriously ill or just old. Bravo to Philadelphia Inquirer writer Stacey Burling for providing a detailed account of the challenges she faced during the final months of her husband’s life last year.

“Taking care of the dying at home is harder, uglier work than many people can manage, especially with the amount of help that our health-care system provides,” she concludes. This, from a medical reporter, who enjoyed full access to good doctors and hospitals and a pre-hospice program and, ultimately, to hospice care.

I discovered I was unprepared for what had been completely predictable – his death. I knew it would be an emotional ordeal, but the mechanics of it took me by surprise. Even after years of medical reporting, I didn’t understand how people with cancer die or how physically and emotionally demanding it is to take care of them at the end. So I, like millions before me, would learn the hard way during the worst month of my life. We put a lot of effort into helping people live with cancer, but not enough into revealing what it will be like to die of it.

Burling concludes, “I came to wish that I had asked more questions, more insistently, and that the doctors and nurses who worked so hard to keep my husband alive had talked openly – before there was a crisis – about what my role as a caregiver would be like when their work was done.”

Bill Sez: This article provides a timely reminder to hospice advocates (like me) that, even with hospice services, family caregivers are often asked to shoulder a huge caregiving burden. Read the whole piece. And consider, too — should Medicare really be cutting payments to all hospice providers because some of them (for-profit agencies) may be gaming the system?

Best health-care system in the world…not (2)

March 14, 2011 Leave a comment

Medicare spending on medical care at the end-of-life is much higher in Los Angeles than in San Diego, yet quality measures tend to favor San Diego, according to a study published in the Journal of Palliative Medicine.

Using Medicare and state health planning and outcome data, Robert M. Kaplan of the UCLA School of Public Health explored differences in health care use by Medicare beneficiaries living in the two California counties.

During the last two years of life, total costs among Medicare decedents were 42% higher in LA than San Diego, Kaplan found, even though “the disease burden in the two areas appears to be approximately equal.”

Read more…