The Real Advance Planning

Michael Kinsley’s Old Age: A Beginner’s Guide isn’t exactly a guidebook to “life’s last chapter,” as the author promises. The book does talk quite a bit about Parkinson’s disease, even though Kinsley assures us that it isn’t really about Parkinson’s disease, because that’s been Kinsley’s diagnosis for the last 23 years. And his comments about going through “deep brain stimulation,” a surgical technique that can be very helpful to people with Parkinson’s, as well as his discussion of accepting limitations—giving up driving, realizing you’re not going to be promoted—are illuminating. His suggestion that the baby boomers redeem themselves for posterity by erasing the national debt is whacky. But he does deal with something tremendously important, and that is coming up with an immortality project.

I first learned about immortality projects when I read Ernest Becker’s The Denial of Death, which was published in 1973. It had such a profound effect on me that I called my book about aging The Denial of Aging in homage to his. Becker’s point, at least as I remember it, was that it is the awareness of our mortality, more than anything else, that distinguishes us from other mammals. 

Now I don’t know if it’s really true that apes are totally oblivious to the prospect of death. But regardless of whether we are unique in this respect, I do think it’s fair to say that our recognition of our finitude profoundly shapes our existence. Some moral philosophers have even suggested that the prospect of further life extension is bad for us as it would induce a kind of ethical laziness—we would keep on putting off doing good because we figured we’d have plenty of time later. That may be a bit of an exaggeration, but I think there’s truth to the claim that mortality is a great motivator. I don’t think it’s necessary to invoke heaven and hell, some kind of post-mortem day of judgment, to induce people to lead a good life. It’s sufficient to realize that our time on earth is limited: if we want to make something of our lives, we better go ahead and do so. And built into the fabric of our being is a desire to live on after our death, to be remembered, and in that way, to triumph over our mortality. Which is where immortality projects come in.

What Kinsley’s book is about is finding an immortality project. He recommends that the baby boomers undertake a joint project with all the other baby boomers (eradicating the debt), which is more daunting and, in my view, less likely to succeed than embarking on an individual project. But Kinsley’s point is that being diagnosed with a chronic, progressive (and I would add, ultimately fatal) disease brought home to him the recognition that he had better get started. It made him think about what was really important to him—was it material possessions? Was it fame? Or was it something more durable?

Kinsley is telling us is that we need to get cracking. We better define our immortality project, our legacy, and start working on it. For Kinsley, it was the diagnosis of a serious disease that helped him figure out that he ought to have such a project. But for most people, that’s a little late. The real message of his book is not to wait. Don’t wait until you already know what disease is going to kill you. Don’t wait until you have dementia or widely metastatic cancer or advanced heart disease. We’re human: we are mortal and we know it. We should all be working on our legacy for much of our lives, where “legacy” may simply mean being the best person we possibly can be.

No Quick Fix for Mortality

Quercetin hit the airwaves this week, when the media reported that scientists have found "a new class of drugs that dramatically increases healthy lifespan.” Not to be confused with Coenzyme Q10, another naturally occurring compounded touted as an antioxidant that delays aging, Quercetin is a “natural compound” sold in health food stores as an anti-inflammatory agent. But now it is has been dubbed a “senolytic,” a drug that slows aging by alleviating symptoms of frailty, improving cardiac function, and extending a healthy lifespan. Sounds great. But before you rush to buy some, lets look at the evidence.

The article on which this promising claim is based is a highly technical paper in the journal Aging Cell entitled, “The Achilles’ Heel of Senescent Cells: From Transcriptome to Senolytic Drugs.” The authors argue that aging is due in large part to cellular senescence, which in turn means the process by which cells lose the capacity to grow. These senescent cells secrete all kinds of chemicals that are hypothesized to produce decline and death. But not all the cells in an organism become senescent at once. In fact, only 15% of the cells of very old primates are “senescent.” The idea is to kill off these senescent cells, thus preventing them from making those disease-making chemicals. 

It turns out that a variety of drugs, all belonging to this new class of “senolytics,” selectively kill senescent cells. And indeed, when a combination of two drugs, a known cancer drug and the compound Quercetin, were given to old mice, they lived longer and had lower rates of “age-related symptoms and pathology” compared to old mice that didn’t get the cocktail. The two drugs worked especially well together, but each drug alone was effective. So where’s the rub? Why not rush out and buy some Quercetin, which is available now and without a prescription?

It’s not that Quercetin might be harmful. The FDA has studied the compound and determined that it has no significant toxicity because it is destroyed in the intestinal tract--before it can even get into the bloodstream. So while the drug might in principle do something if given intravenously, taking the currently available formulation won’t. Parenthetically, you certainly don’t want to buy some Dasatinib either, the other drug used in the study. Dasatinib is a “targeted chemotherapy” drug, used to treat the relatively rare blood cancer, Chronic Myelogenous Leukemia (CML), when the preferred drug, Gleevec, stops working. It costs roughly $10,000 for a thirty-day supply. It is approved only for use in blood cancers, though in principle it could be prescribed off- label for other non-proven indications.

Another reason for holding off on your Quercetin purchase is that its effectiveness has been demonstrated only in rodents. Using mice to explore the genetic underpinnings of mortality has a venerable history: the gerontologist David Sinclair, for example, has been using a mouse model to study Sirtuin genes, genes that appear to protect against aging. He has discovered "sirtuin-activating compounds," small molecules that decrease frailty--in mice. These frail mice exhibit muscle weakness, they get heart disease, and they die earlier than their non-frail counterparts. But whether frail mice are truly analogous to humans, in whom frailty entails heightened vulnerability to stressors, and in whom frailty translates into an increased risk of falls, delirium, and disability, is another matter.

The main reason for skepticism about the latest claims about an immortality pill goes back to the article written by Olshansky, Hayflick and Carnes in 2002 and republished by Scientific American in 2008 that debunks all claims to have discovered the fountain of youth. These scientists take seriously the desire to promote healthy aging. They see the virtue in postponing the aging process altogether rather than tackling the diseases of old age one at a time: if aging is a zero-sum game, then curing cancer, for instance, would simply mean that more people will die of Alzheimer’s disease. But they are horrified by the amount of money desperate people spend on anti-aging products that are no more likely to be beneficial and just as apt to be harmful as many of the quack nostrums of the nineteenth century.

Today, a number of companies are peddling “anti-aging” drugs. Elysium, cofounded by Lenny Guarante of MIT (David Sinclair’s mentor), makes “Basis,” a mixture of nicotinamide and pterostilbene (an anti-oxidant), which it sells on line. Even Novartis, a major drug manufacturer, is trying to get into the anti-aging market with rapamycin, as Bloomberg News reported with enthusiasm.

None of these drugs has been proven to work. Some may be harmful. All are costly. It's not necessary to discuss  the ethical concerns about trying to lengthen the human lifespan to have an opinion about Quercetin. It's an interesting chemical for scientists to study in the laboratory, but it's not ready for prime time.

Farewell to All That

In his 1905 farewell speech to the faculty of Johns Hopkins University Medical School, Dr. William Osler commented that the school was wise to hire someone young and energetic in his stead (he was very distinguished—and 55 years old). In passing, he mentioned Anthony Trollope’s satirical novel from 1882, “The Fixed Period,” in which all 67-years olds are to be sent to a special sanctuary, a kind of cross between a high-end resort and a liberal arts college, and given one year to put their affairs in order. At the end of the year, the plan is to chloroform them. The idea was to make sure that everyone quit while he was ahead, without waiting for the decline thought to inevitably accompany aging. Osler’s speech sparked a huge outcry in the media, which inveighed against his alleged endorsement of universal, mandatory euthanasia. Osler, who was well known as a joker and prankster, had endorsed no such thing. His remarks about the “comparative uselessness of men over 40 years of age” and his recommendation for compulsory retirement at age 60 were said tongue-in-cheek.

A similar media frenzy ensued nearly 80 years later when then governor of Colorado, Richard Lamm, was quoted as saying that elderly, terminally ill patients "have a duty to die.” Lamm hastened to assure the public that he didn’t actually mean that seriously ill patients should commit suicide, assisted or otherwise. What he meant, or so he insisted, was that it made no sense from a societal perspective to expend enormous resources on medical care for the dying. His choice of words was unfortunate, as was his failure to acknowledge that another reason for limiting care near the end of life was precisely that it aggressive treatment did little, if any good, not merely that it cost a lot.

Now enter Ezekiel Emanuel, an ethicist, physician, and health policy guru, with his loud proclamation that once he reaches the age of 75, he wants treatments devoted only to his comfort, not to prolonging his life. Emanuel, unlike Trollope and Lamm, is dead serious, as his article in the Atlantic, "Why I Want to Die at 75," attests.

At its core, his argument shares the legitimate concern of his intellectual predecessor, philosopher Daniel Callahan, that failure to accept our inevitable mortality is leading us to make foolish decisions about medical care. As patients we choose, as a society we pay for, and as researchers we pursue treatments that offer a vanishingly small possibility of prolonging life, treatments that come with tremendous physical and emotional suffering and enormous cost. To the extent that Emanuel is arguing that this approach is wrong, I agree with him entirely. To the extent that Emanuel is arguing that we as individuals need to revise our goals of medical care as we age, I agree with him entirely. But to the extent that he is arguing that life is worthless after age 75 and that it would be better to forgo all medical care except that focused on comfort after one's 75th birthday, I think he is fundamentally misguided. 

Of course if Dr. Emanuel wishes to decline medical treatment in the future, that is his prerogative. Contemporary biomedical ethics teaches respect for individual autonomy, which means every individual is free to refuse any (or all) proffered medical treatments. So why should anyone apart from his friends and family, and perhaps his physician, care about the personal decisions that Emanuel makes about his medical care? The reason that people care—and that there has been a strong and negative reaction to Emanuel’s announced plans—is that they rest on various assumptions which, if true, would suggest that everyone else ought to consider the same approach. So it is essential to examine critically Emanuel’s views of what matters in life and his implicit belief that the only possible goals of medical care are either maximization of comfort or prolongation of life.

As a quick way to get a sense of what Ezekiel Emanuel considers important, take a look at PubMed, which lists all published scientific publications. Emanuel published 19 articles in 2013, almost all of them in leading journals including the New England Journal of Medicine, JAMA, and the Lancet. And that doesn’t include all his New York Times op-ed pieces (he is a “contributing opinion writer” for the Times), which arguably are far more influential. Now move on to Emanuel’s bio. He is Chair of the Department of Medical Ethics and Health Policy and Vice Provost for Global Initiatives at the University of Pennsylvania. As to what he does in his spare time, apparently he climbs mountains—the Atlantic article features a photo of him and his two nephews, with whom he recently climbed Mt. Kilimanjaro. Dr. Emanuel (he is also an oncologist) continues, at age 57, to function at a level that many would place somewhere off in the stratosphere.

So Emanuel is something of a superman and he’s concluded that when he stops being able to keep up his current pace, he can’t imagine that life will be worth living. Not that he plans to commit suicide or to ask anyone else to end his life. He will simply forgo all potentially life-prolonging therapy and die at the earliest opportunity. Now here is the first place where Emanuel is sadly misguided. He fails to understand or at least acknowledge the importance of any dimension of life other than what he has thus far experienced—success measured by the publication count and the prestigious positions, the mountains scaled, literally and metaphorically. It’s not just that proclaiming that life must be lived at a fevered pitch or not at all seems to categorize most of the rest of us as not-living-a-worthwhile-life; after all, Emanuel doesn’t claim to be imposing his standards on everyone else. It’s that Emanuel’s relentless desire for a narrowly defined kind of accomplishment gives short shrift to precisely those activities that many cultures deem of greatest value. The Jewish tradition, for example, calls upon every individual to participate in acts of loving kindness (gemilut chasadim) and in efforts to repair the world tikkun olam), however small those efforts.  Every stage of life comes with its challenges and its possibilities and it’s up to us to try to do our best in whatever condition we find ourselves.

But while I feel sad that such a talented and (otherwise) insightful person as Dr. Emanuel fails to see any merit to a life other than the one he is currently leading, that is not my main criticism of his stance. Nor is my main criticism that he is naïve if he believes that forgoing life-prolonging therapies such as pacemakers and antibiotics will necessarily shorten his life, when many people live for years without such treatments. Moreover, excluding a treatment from consideration merely because it might lengthen life may well have several presumably unintended consequences: refusing a flu shot (in the hope that you might contract the flu, develop complications, and die, a relatively unlikely outcome) has public health consequences as you may transmit the flu to others who do not share your death wish; and declining a pacemaker (in the hope that a slow heart rate might be lethal) may result in falls, broken bones, and dizzy spells all of which impair your quality of life without killing you. The primary difficulty I have with Emanuel’s perspective is that he completely misses the possibility that someone might have any other goal aside from maximizing comfort, on the one hand, or prolonging life, on the other. My view is that this is in-between position that Emanuel ignores is precisely what most people find themselves endorsing as they age.

We are both mortal and at high risk of experiencing increasing disability in the last couple of years of life (though not, as Emanuel seems to think, starting at age 75). The implication of these realities is that when death appears on the horizon (if, for instance, you develop a fatal illness) or when frailty rears its head (if, for example, you develop one or more impairments in your basic daily activities), it is a signal to reconsider the goals of medical care. Most people, I have suggested elsewhere in this blog as well as in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, choose comfort as their primary goal if death is imminent and choose maintaining their daily functioning, that is maximizing their quality of life, if they are becoming frail. Most people make this switch even though they continue to wish for a longer life; they are simply saying that if the price they have to pay for longer life is pain and suffering (in the first case), or poor quality of life (in the second), they are not interested. Dr. Emanuel, in his black-and-white, all-or-nothing view of the world, fails both to recognize that there is a middle ground where people choose treatments that promote quality of life, and that decisions to forgo treatment are predicated on the need to make trade-offs, not on the wish to die.

I hope that in all the furor over Dr. Emanuel’s article in the Atlantic—and he has certainly triggered a storm of protest—we will be able to get beyond the arrogant implication that only a life of intense and continuous activity is worth living, and accept the more modest reminder that is at the heart of his article: that we are all mortal. And as we approach the end of our lives, we may wish to modify our hopes and expectations in accordance with the reality of our situation and seek medical treatments that correspond to our new goals of care.

The Methuselah Prize

A startling new project was unveiled last Tuesday in the San Francisco Bay area. No, not Apple’s iPhone 6 or its watch, but the Palo Alto Longevity Prize. Never heard of it? Well, you still have a few more months to sign up to enter the competition to win $1 million for unlocking the secret to immortality. Is this just hype or is there some hope here for an important scientific breakthrough?

The basic idea is this: what we are doing now, attacking the maladies of old age one at a time, is simply trading off one bad disease for another. We’re already succeeding: the death rate from cardiovascular disease has fallen over the past several decades—and the death rate from Alzheimer’s disease has risen. As long as human life expectancy remains stable, we’re talking about a zero sum game in which you fix one problem and substitute another. So far, it looks as though dementia will be the big winner, which makes research aimed at turning off the switch that triggers all the diseases of old age very appealing. The underlying assumption of longevity research is that the degenerative diseases such as cancer, heart failure, and dementia are the result of the aging process. Preventing all the conditions that both limit life’s duration and impair its quality seems far more attractive than the disease-specific approach. But is it feasible and is it ethical?

The majority of credible scientists believe that life-extension is a very hard problem whose solution is not around the corner. The Palo Alto Longevity Prize, to the credit of its mastermind at Palo Alto Investors, Yoon Jun, is focused on somewhat more modest and potentially achievable goals. Part one of the prize is $500,000, to be awarded in June, 2016. It will go to a team that can restore the adaptive capacity of a laboratory animal; specifically, an aging animal will need to regain the heart rate variability characteristic of its youth. Part two of the prize is another $500,000 award, to be granted a year later to a team that increases an animal’s longevity by 50%. In both cases, the scientists will have to achieve their goal by enabling the animal to preserve homeostasis—the ability to maintain the status quo (temperature, blood pressure, etc) in the face of a stimulus, a capacity that is gradually lost with aging. Is this a worthwhile goal?

Impaired capacity for homeostasis is at the heart of frailty. The reason people lose their balance and fall easily, or get pneumonia when they contract the flu, or become confused when they are hospitalized is that they are vulnerable to modest “stresses.” So the key to physical frailty, and quite possibly to cognitive frailty (dementia) as well, is maintaining homeostasis. The Longevity Prize seeks to figure out how to do just that, but it is not without risks. As the Struldbrugs of Gulliver’s Travels showed, immortality without eternal youth is tantamount to hell-on-earth: failing vision, declining hearing, impaired cognition with no escape through death. Suppose unlocking the key to immortality does indeed prevent cancer and heart disease—but not arthritis and visual loss? The idea is to prevent all the degenerative conditions of old age, but suppose there isn’t just one switch, but several?

Even if we had confidence that achieving a longer life would not create a race of Struldbrugs, is it a good idea to devote scarce resources to trying to find the key to immortality? As NIH funding shrinks and the need to prioritize research questions grows, surely there are more urgent medical questions than how to live longer. Most people would opt to prevent premature death (infant mortality, teen suicide, cancer deaths in middle age) before they seek life-extension past the biblical allotment of three score and ten. Most physicians who witness the numerous ways patients suffer throughout life’s trajectory would recommend focusing on quality of life before quantity. And many people worry that if researchers did come up with an elixir of life, it would be so expensive that only a very small number of people could afford it, creating a new elite of Immortals.  So perhaps government should not fund longevity research, but what about the private sector? Google invested in Calico, a biotech startup devoted to finding ways to reverse aging. Earlier this month, Calico opened a new research facility in San Francisco where many talented scientists will search for the elusive spigot that can turn off the aging process. People in a free society choose to do all kinds of surprising things: they go bungee jumping, they sign up to travel to Mars, they smoke cigarettes. If Google wants to invest some of its advertising revenue on preventing the degenerative conditions associated with aging, why not?

If it’s reasonable to work on longevity, is offering a prize the right way to go? This approach got quite a bit of media attention a few years ago when Netflix promised $1 million to an individual or team that could improve its predictions of the movie ratings of individual viewers by 10%. This challenge stimulated a great many computer science graduate students and faculty members to spend hours trying to solve the problem. I know because my oldest son was one of them and he wrote about the math underlying the Netflix challenge for the on-line science journal, Science 2.0 when, after 3 years, a winner was announced. It turned out to be a good strategy for Netflix: for a relatively modest investment, the company recruited many fine minds to work on what would prove to be a difficult problem, without having to pay benefits or to pin their hopes for a solution entirely on one individual. Other organizations have issued similar challenges: the Millennium Prize, for example, announced by the Clay Mathematics Institute in 2000, offers $1 million for the solution to each of 7 great unsolved mathematics problems. As of today, only one of the 7 has been solved (and the individual to whom it was awarded, the reclusive and quirky Russian mathematician Grigori Perelman, declined the prize).

Perhaps the earliest use of a financial incentive to solve a scientific problem was the “Longitude Prize,” offered by the British Parliament in 1714 for an answer to how sailors could correctly establish their position at sea. Sailors had long used the stars to determine their latitude, but until the clockmaker John Hunter got his 20,000 pounds (worth about $5 million today) for solving the longitude challenge in 1765, they had been unable to determine their longitude. In recognition of the success of the first Longitude Prize—it was probably the last great breakthrough in navigation before Global Positioning Systems—a public private partnership in England recently launched the Longitude Prize 2014. This competition took an old approach and added a new wrinkle. A panel of experts came up with a list of 6 scientific problems in desperate need of a solution, and then asked the British public to vote on which one to sponsor. The election was held in June and the winner was the problem of antibiotic resistance: designing an easy to use, cost-effective way to test for antibiotic sensitivity at the point of care (which in turn would prevent doctors from giving a drug to which the relevant germ would not respond, an all too common scenario that both fails to cure the patient and also promotes further antibiotic resistance). The winner will receive 10 million pounds (about $16 million). Whether the competition will achieve its objective remains to be seen.  In many such competitions, including the Millennium Prize discussed above, nobody ever wins.

In sum, I doubt very much that the Longevity Prize will result in immortality and I’m glad that it’s a hedge fund and not the NIH that is sponsoring the competition. That said, it’s entirely possible that there will be valuable spinoffs from the kind of research that the prize is fostering, much as 19^th century anti-aging experiments using animal gland extracts led to hormone replacement therapy and tissue transplantation was stimulated by early 20^th century experiments in rejuvenation through grafting. 

Politicians: Keep Out

This past week, 150 Congressmen sent a letter to the Centers for Medicare and Medicaid Services (CMS), urging that it approve reimbursement for lung cancer screening with lowdose CT scans. These legislators are trying to exercise their political muscle in an arena where they have no business intervening. Medicare has a fair, transparent, and extremely thoughtful process for deciding what tests to cover. The attempt to destroy this honest, objective, and time-tested process by injecting political pressure is reprehensible.

The Medicare program is required by statute to limit coverage to tests and services that are “reasonable and necessary” for the treatment of illness.  Most “coverage decisions” continue to be made by local intermediaries, the regional contractors that function as Medicare’s agents throughout the country. But occasionally, for particularly important decisions, Medicare issues a National Coverage Determination which is then binding on all its intermediaries.  A few months ago, CMS was asked to make a decision about paying for lung cancer screening using low-dose CT scans. It has diligently been conducting a thorough, comprehensive assessment.

What Medicare often does is to ask MEDCAC, the Medicare Evidence Development and Coverage Advisory Committee, to collect information about the procedure it is supposed to evaluate and to discuss, publicly, its evaluation of the information. MEDCAC is an independent panel of 100 people, drawn from medicine, industry, science, ethics, public health, economics, and the public, from whom up to 15 people are chosen to address any particular issue that comes up. Medicare asked MEDCAC to review low-dose CT screening and on April 30,  the committee had an all day meeting. The agenda is available on line. The evidence was presented and discussed. The committee voted—each person’s vote is public and each person was asked to explain the rationale for his vote. What the committee concluded was that the evidence supporting the use of low-dose CT scanning to screen for lung cancer in the Medicare population just wasn’t there. The transcript of the entire meeting is on line. It runs to 310 pages.

To be precise, the committee members were asked “how confident are you there is adequate evidence to determine if the benefits are greater than the harms” for Medicare enrollees. They could vote  from “1” (little confidence) to “5” (high confidence). The average vote was 2.33. But the US Preventive Services Task Force, another independent body of experts, had recently given low dose CT scanning a “B” grade, recommending that it be used in people ages 55-79 who have a 30 pack-year smoking history and are currently smoking or have quit within the last 15 years. How could MEDCAC vote no and USPSTF vote yes?

It turns out that the members of the USPSTF didn’t exactly vote yes. They suggested excluding people with “a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.” The reason for this caveat is that screening for lung cancer, like screening tests in general, only makes sense if early detection leads to cure or at least more effective treatment. And the only truly effective treatment for the vast majority of cases of lung cancer in smokers is surgery. Major surgery: removal of all or part of a lung. So the question for Medicare is whether doing major surgery in older people with lung cancer is a good idea. 

The single study on which the USPSTF recommendation was principally based, the National Lung Screening Trial, though it included 52,000 high risk individuals randomized to screening with low-dose CT or screening with an old fashioned chest x-ray, included relatively few people over 65 (26%), very few people over 70 (9%), and few individuals with other health conditions. So when this study, which by the way was funded by the National Cancer Institute, part of the National Institutes of Health, reported that the death rate was 20% higher in people screened with a conventional x-ray than in those screened with low-dose CT scan (based on a reduction in the death rate from lung cancer from 309/100,000 to 247/100,000 in 6.5 years), its conclusion rested on the 79 excess lung cancer deaths (425 vs 346) in those getting regular x-rays. In other words, 320 people had to be screened to prevent one death. We do not know how many of these 79 deaths were in older people; we do not know how many of these 79 deaths were in people with other serious illnesses such as heart disease or diabetes; and we do not know, for those who survived their lung cancer, how many would go on to die of other illnesses in the near future.

It was based on this kind of analysis that MEDCAC determined there just wasn’t enough evidence to justify ordering Medicare to reimburse for the screening of high risk older individuals with low-dose CT scanning. It didn’t say low-dose CT scanning doesn’t work at all: it said we don’t have enough information about older, sicker patients. It didn’t say low dose CT scanning won’t work in older people: it said there isn’t compelling enough reason to mandate reimbursement for this test and treating such patients for lung cancer with surgery, the only treatment associated with a high cure rate, might in fact do more harm than good to such individuals.

The specific reasons that MEDCAC chose to vote no to Medicare reimbursement are not actually terribly important—though I’ve included some to give a sense of the reasons that were invoked, and all the reasons are publicly available—what is most important is that the rigorous, evidence-based process on which the decision was based be honored. Medicare has yet to issue an “NCD” (National Coverage Decision). It could still be swayed by political pressure, by lobbyists, by emotional personal stories of individuals whose lung cancers were detected by low-dose CT scanning and who believe their survival hinged on this. The 150 lawmakers who are pressuring Medicare are hoping to achieve exactly this end. If Medicare is to remain the excellent insurance program that it in many ways is, it must do what all third party insurers have to do: decide what to cover and what not to cover. And it should make that decision based on the facts, not on the ignorant screed of politicians.

A Rare Win Win in Medicine

How often does anyone come up with an idea for improving medical care that does good and saves money at the same time? Not very often. Even inventions that ought to save money often don’t—for instance, a number of years ago, surgeons figured out how to take out a person’s gallbladder using a fiberoptic device called a laparoscope. Instead of a five-inch incision, patients have a one-inch incision; instead of a 5-day hospitalization, they spend a single night in the hospital; instead of a 6-8 week recuperation period, patients are up and about within days. Good idea? Absolutely. Money-saving? Not so clear. What happened is that the rates hospitals charged for the procedure were based on the “equivalent” alternative procedure that insurers were used to paying for, so the per procedure charge wasn’t much less than standard gallbladder surgery that involves cutting open the abdomen. Not only that, but the total number of people getting gallbladder surgery went up dramatically after the simpler procedure was introduced. Net result? No decrease in overall spending on taking out people’s gallbladders. So when something comes along that both improves outcomes and saves money, it’s worth taking note and celebrating. Palliative care, as a recent article in the New England Journal of Medicine points out, is exactly that kind of remarkable invention. 

Palliative care is not synonymous with hospice care. It is not the same as end-of-life care. And it is not a court-of-last-resort, what you get when you’ve exhausted all possible other treatments. Palliative care, as the Center for the Advancement of Palliative Care defines it, is “an extra layer of support,” something that is appropriate at “any stage in a serious illness.” Patients can have palliative care and life-prolonging treatments; they can, for instance, have chemotherapy or radiation therapy as treatment of cancer along with palliative care. What palliative care adds to conventional treatment is a whole team of clinicians (typically a doctor, nurse, and social worker, though it can include a chaplain or music therapist or other professional) whose focus is on managing symptoms (problems such as pain or nausea or depression), on advance care planning (on preparing for future medical care), and on providing psychosocial support to the patient with a life-limiting illness and his or her family. 

Several studies have now shown that early palliative care improves quality of life and may even lengthen life. In advanced lung cancer, in which patients typically have a prognosis of at most a year, patients who received  outpatient palliative care along with conventional cancer care were less depressed, had fewer physical symptoms, and actually lived longer than those who did not get palliative care. Similar findings have been reported for people with severe heart failure, severe chronic lung disease, and for people with multiple sclerosis. My clinical work suggests the same is true for older people with physical frailty or with cognitive frailty (dementia).

What’s remarkable is that palliative care also saves money. It leads to shorter hospital stays, fewer days spent in an intensive care unit, and fewer expensive tests, all without shortening life. But most patients with life-threatening illnesses do not receive palliative care services? Why not? The New England Journal article suggests that the way to improve the situation, and implicitly the reason for the current limitations, is by changing the payment system so that insurers would pay physicians for counseling about end of life care, by reforming the medical education system to increase palliative care training, and by improving access to palliative care by making consultation available at all hospitals. These are all reasonable strategies, but I don’t think they get to the heart of the problem. 

The main barrier to extending the benefits of palliative care more widely is not economic—palliative care physicians have been successfully billing Medicare and other insurers for their services for years by transforming a “family meeting” into a “history and physical examination” through the inclusion of a few comments about the patient’s medical problem (the “history”) and appearance (“physical examination”) into the medical record. The main barrier to more widespread use of palliative care is psychological. Even though patients and their families who do avail themselves of palliative care generally like what they get, many patients refuse palliative care services because they do not want to face their mortality. At the same time, physicians do not want to propose palliative care because they think they are conceding defeat in the “fight against death.” And Congress does not want to legislate changes in Medicare and Medicaid that mandate broader use of palliative care because of the "death panel" legacy. The truth is that we are all mortal.  The question is not whether we will die but what our journey will look like. Maybe it’s time to face this reality.