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End-of-life Care: A National Conversation

Posted by Tana Phelps

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End-of-life care can be a difficult conversation for many people and for many reasons. Patients and their loved ones may not be emotionally ready to handle that subject until it’s too late.

End of life care needs to be a top-of-mind conversation for health care providers.Physicians are trained to provide life-saving and life-prolonging medical treatment, even if it only extends the patient’s life by a few short days or weeks. Nurses and other professional caregivers may have limited knowledge of end-of-life care or may think it isn’t their place to approach the issue with patients.

But modern medicine is keeping people alive well past their ability to make decisions. Once mostly fatal conditions such as pneumonia and massive heart attacks have been replaced by chronic, progressive diseases such as heart disease, advanced cancers and Alzheimer’s.

In 2006, the last year for which data is available, more than one-quarter of Medicare spending was for care during a beneficiary’s last year of life, much of which is spent in the last few weeks of life and often for aggressive-yet-futile treatments that offer little to no lasting benefit.

End-of-life care can take an emotional and financial toll on patients and caregivers – and the increasing costs are crippling the U.S. health-care system. Communication and collaboration between patients, caregivers and health-care professionals is key to ensuring patients’ wishes are carried out while reigning in costs for all involved.

The Barriers

There are several barriers to the conversation about end-of-life care. People don’t want to talk about death and dying. When it comes to dying, many are willing to exhaust all means possible to keep loved ones alive, according to The Washington Post. One reader said, “Americans are unwilling to die gracefully, even if it bankrupts their children’s and our country’s future.”

Another barrier: Physicians are in the business of healing, and some see palliative and hospice care as “giving up.” Others simply are not aware of the options. Nearly 90 percent of patients with cancer have documented end-of-life care discussions with their physicians, according to a study in the Annals of Internal Medicine. But most of the talks happened in the hospital less than five weeks before death and were with physicians other than the patient’s oncologist.

Additionally, the “death panel” debate from health-care reform illustrated Americans’ distrust in physicians and politicians’ seemingly do-good initiatives. The “death panel” label was placed on a provision in the 2010 health-care law – later upheld by the U.S. Supreme Court. The failed provision encouraged physicians to discuss end-of-life care with their patients. Opponents argued that it would lead to rationing and other unethical decisions by physicians.

The Costs

One of the primary goals of health-care reform is to slow the growth of Medicare costs. As baby boomers live longer, they place huge demands on the health-care system, according to Nursing Economic$. At the same time, rising costs threaten Medicare just as millions of boomers are turning to it for health insurance coverage.

A sliver of the sickest patients accounts for the majority of health-care spending, the Wall Street Journal reports. In 2009, 10 percent of Medicare beneficiaries who received hospital care accounted for 64 percent of the program’s hospital spending.

Demand for Palliative Care Grows

Hospice and palliative care can impact care costs considerably. While the average hospital stay costs Medicare more than $6,000, hospice and palliative care hovers around $400 a day, according to a New York Times article.

As hospitals face shrinking budgets, they are turning to palliative and hospice care as cost-saving measures. In 2000, fewer than 700 hospitals had palliative care programs. That has since doubled, and continues to grow as hospitals face more pressures to reduce operating costs under health-care reform.

Hospitals also are adopting a new model of palliative care. The traditional care concept meant that active, curative care discontinues when palliative care starts near the end of life. Patients either opt for treatment or palliative care, but do not receive both simultaneously. Under the newer model, palliative care begins at the diagnosis of a life-threatening or life-limiting disease. It takes a greater role as the disease progresses, whether it’s a matter of weeks, months or even years.

Recent data shows the benefits of palliative care early in the course of treatment for serious illness. A study found that when palliative care is delivered in tandem with standard cancer treatment, it helped patients feel better and live longer than compared to patients who received standard treatment alone.

Planning Ahead

It’s never too early to have the end-of-life conversation with loved ones. At the onset of a chronic illness or life-threatening disease, patients should be advised to make their wishes known in writing through an advance directive. This legal document guides decisions about medical care and designates a surrogate for making medical decisions if the patient can no longer do so.

A wide body of research has found that patients who plan ahead are more likely to get the treatments they want as they near death. These patients tend to get less-aggressive care, earlier referral to palliative and hospice care, are more satisfied with their care and see lower emotional and financial burdens placed on family members, experts say.

Health-care professionals should encourage patients and families to not only put their wishes in writing, but to provide that documentation to the health-care team. Even then, health-care professionals can expect to experience conflict between family members and other caregivers.

“One child thinks we need to save Mother at all costs, while another one says we need to take a different route,” said Alice Greer, RN, BSN, CPHQ, quality research analyst at Blue Cross Blue Shield of Tennessee. “If the advanced directive is clear and concise and shared with the health-care team, we can ensure our patients’ wishes will be carried out when the time comes.” 

Topics: Patient Outcomes


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