Aging Options

Making changes in end-of-life care may finally make it more sustainable

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In Field of Dreams, Ray Kinsella hears a voice saying, “If you build it, he will come.”  Unfortunately, the same is true of hospital beds.  “Today,” according to Sharon R. Kaufman in her 2005 book, And a Time to Die: How American Hospitals Shape the End of Life, more Americans die in hospitals than anywhere else, and the most frequent response to critical illness there is to stave off death with the most sophisticated technological means available.”

That’s especially true if you live in New York or New Jersey than if you live anywhere else in America. Experts believe, at least part of the reason for the phenomenon is, that the region has so many hospital beds that the health care system’s culture encourages it.  There, more than anywhere else, people die hooked up to ventilators or feeding tubes, see more doctors at the end-of-life, go through more treatments and drug prescriptions and spend more money.  Ultimately, it’s about money—the patient’s money, the insurance company’s money and the government’s money.

And while New York and New Jersey have a greater degree of problem with it by far, the reality is that Americans struggle with coming to grips that some day they will die.  Just hearken back to Sarah Palin’s 2009 “death panel” quote, which still, despite being debunked, gets resurrected whenever someone suggests that doctors should provide end-of-life counseling.  This leaves doctors in a precarious position of inadvertently suggesting to someone a more optimistic prognosis with treatment than is warranted.  If doctors see death not as a realistic outcome but as “losing the battle,” it will be up to the patient to ask for treatment that provides the most meaningful improvement in his or her life rather than the one that will postpone death the longest.

A new report from the Institute of Medicine  seeks to find measures that will promote a reasoned and public discourse on the subject of health care at the end-of-life and how family members, health care providers, spiritual leaders and others can help to make the final days better for the patient.  To achieve those aims, the institute reported, patients, family members and those caring for family must take four measures.

  1. They must realize that those nearing the end of life are often unable to make their own decisions about care and that they often receive care at that point in their lives from care professionals who do not know them. Therefore they must take the time and energy to provide instructions about the care they wish to receive so that it will reflect their own values, goals and preferences before those decisions are removed from their hands.
  2. The point of hospital care is generally to provide acute care. Those patients looking to alleviate pain and suffering must choose care accordingly.  Many studies already performed have found that patients in palliative or hospice care often live longer and live better lives than those who choose more aggressive treatment options.
  3. Health care workers need to initiate conversations and provide solid information about end-of-life goals, values and preferences especially with those that are poorer, younger, less educated and minority individuals who are less likely to have that conversation.
  4. Finally, despite the risk of “death panels” rearing their ugly heads again, society as a whole needs to provide the incentives, quality standards and support systems necessary to promote the kinds of conversations health care providers need to have with patients.

Taking steps to start the conversation and provide meaningful care options will contribute to a more sustainable health care system.

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