Last Chapter or Final Gasp?

An update from the Dartmouth Atlas last week reports that we are making excellent progress in how we care for people at the very end of life. Medicare enrollees spent fewer days in the hospital and more days enrolled in hospice in 2010 than they had a mere three years earlier. Perhaps even more impressive than the overall 9.5% decrease in the number of hospital days per patient or the 13.2% increase in the proportion enrolled in hospice at the time of death is the change in selected institutions. As the Dartmouth Atlas data so often reveal, change is not evenly distributed across all regions or all hospitals. Some academic medical centers, such as NYU's Langone Medical Center, demonstrated a whopping 29.9% decrease in the average number of days spent in the hospital during the last six months of life, from 26.9 days to 19.1 days. At the same time, other centers such the University of California, Irvine, reported an almost exactly equivalent increase in the average number of days spent in the hospital. But buried in the report is some less encouraging news, which the authors mention without comment: in the last two years of life, Medicare spent an average of 15.2% more in 2010 than it had in 2007 (an increase from $60,654 to $69,947).

How can we be doing less of what costs most--hospital care in general and ICU care in particular--and be spending more, not less? Either costs for everything are going up or we are spending proportionately more during what will turn out to be the first 18 months of the last 2 years of life. Sadly, both are probably true. A recent Time Magazine special report brings home the point that some economists have been making for years--it's the prices that make American health care so expensive. We pay more for tests, for hospital care, for physician visits, for medications, and for just about every other component of health care, than our counterparts anywhere else in the developed world. But the other all too probable reality is that though we finally recognize that most patients do not want burdensome, invasive treatment when they are dying, we are if anything more aggressive in our treatment of those in the last chapter of life but not in its final gasp.

It is time to extend the discussion about how best to care for patients near the end of life from those whose deaths are imminent to this larger group who may have months or even a few years to live. These patients are often over 85 years of age and typically have multiple chronic conditions such as heart disease, lung disease, and diabetes or a serious, advanced illness such as cancer or dementia or Parkinson's disease. Predicting how much time they have left may be difficult but projecting what they are likely to experience in their remaining time--progressive decline, increasing dependence, lower quality of life--is not. These are patients who are not eligible for hospice care and in most instances want more medical treatment than is typically available through hospice. But when they understand their general health condition, they often say they prefer care that emphasizes quality rather than quantity of life. It is our challenge to find ways to deliver that kind of care, substituting labor-intensive for technologically-intensive treatment and home care for hospital care. Only when we shift our gaze to life's last chapter will we both improve the quality of care for the sickest, most vulnerable elders and at the same time lower costs.