Healthcare Cost Containment Part IV: Dollars and Sense at the End of Life

By David A. Kindig, MD, PhD

Throughout this series, I’ve challenged health care advocates to consider the importance of reducing healthcare costs in a resource-limited world.  A balanced population health investment portfolio should include resources for prevention and the social determinants of health as well as healthcare. To create this balanced portfolio, we not only need to find new revenue streams but we have to take a hard look at our current expenditures and consider specific opportunities for reducing costs. Research by the Dartmouth group has identified two categories where healthcare costs tend to outweigh the benefits: (1) excess subspecialty visits and procedures and (2) end of life care.

Too many subspecialty visits and procedures can potentially be brought under control through a combination of market forces and regulation. But the high cost of dying is a sensitive topic that most policy makers would understandably rather avoid.

This is an area where policymakers need not and should not be involved. End of life decisions are and can be made voluntarily by individuals and families with their health professionals. They can be made solely on the basis of the kind of death an individual wishes to have. For some, trying every treatment or procedure that may hold promise of extending life or quality of life is important. Others may reject treatment of uncertain or unlikely benefit in light of potential disadvantages (such as prolonged discomfort and/or loss of dignity).

Such decisions should be made by private choice, through legal instruments called advance directives. Recent research by Dr. Maria Silveria showed that patients who had such instruments  were more likely to want limited care (93%) or comfort care (96%) than all care possible (2%). This study also showed a strong correlation between having a  document  that explicitly stated preferences for or against all care and receiving care that reflected those preferences.

In a recent New Yorker article called "Letting Go", physician and author Atul Gawande highlights a 20-year effort by health care providers in La Crosse, Wisconsin to get patients to be clear about end of life wishes. By 1996 85% of patients who died had advance directives, and he reports that end of life costs were half the national average. My first wife was a skilled geriatric social worker, and spent much time encouraging patients to discuss and make their wishes known. Health care costs never entered her mind, but I always wanted to quantify the financial impact of each week of her work, which I imagined to be as great as the La Crosse experience cited above.

Containing health care costs is extremely difficult, and has frustrated policy makers and academics and policy makers for decades. I do not mean to over simplify such decisions, which often have to be made with uncertain evidence. Both of my parents made decisions to forego treatment with possible but unlikely benefit, and died with dignity at home. This issue presents a rare win-win opportunity for personal choices to translate into significant healthcare savings. If circumstances allow, I’m planning for a less invasive death. And if someone would let me, I’d donate the savings to improving the health of low-income children.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Comments

[Robert Stone Newsom, PhD]

Well done. The personal touch of descrbing how your personal experiences relate to the socio-economic policy disccusion at hand brought this important topic to life.

[Paul Hunter]

End-of-life decisions in a population can - and in my opinion should - be influenced by policies of health care providers and systems, as they were in La Crosse as David Kindig described. Public education campaigns, sponsored by non-governmental agencies that have no financial incentives to reduce end-of-life care, would be helpful to support such policies.
As a family physician practicing one day a week at nursing homes, I see many families with mistrust of medical providers and misunderstanding of the benefit of medical interventions. In end-of-life discussions the incentives in my position are 1) to clearly state my medical opinion about what medical interventions are likely to relieve pain and maintain functional abilities, and 2) be available to support the family. My system employs a nurse practicioner and a chaplain who spend part of their time specifically devoted to end-of-life issues. I have learned a lot from them.

[David Kindig]

Thanks to Dr. Hunter for this thoughtful comment. I did not mean to say that there is not a role for policy "nudges" for organizations and government. The Medicare hospice program which both of my parents benefited from facilitated the end-of-life decisions they made. And the La Crosse Gunderson-Lutheran policy decision to educate about advance directives was necessary for their results. However, I did want to emphasize that this is a decision that properly resides with individuals and families, NOT insurance companies or governments.

[Danelo R Canete, MD]

The end-of-life issue should be tackled head-on because it uses up 27% of our health care dollars.
The stumbling block has been the inability to find a copy of the Living Will when patients present to the ER or ICU
Simplify finding the Living Will by putting a notation in the drivers license.
Better still, put a chip somewhere in the body that can be scanned.