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Health Care at the End of Life

I thought I should start with a topic that is easy to address and that most people feel quite ambivalent about (where is that /sarcasm tag, anyway?).

The decisions facing patients, providers and CMS (given that much of this care is funded via Medicare) as to what constitutes desirable (and cost-effective?) health care at the end of life are enormously challenging.   Such decisions are often fraught with concerns over balancing the sanctity of an individual’s life with the realities of tremendous amounts of money being spent on minuscule chances of recovery to at best a highly compromised state of living.   As technologies have developed, the possibilities for sustaining life have increased substantially.  But along with increases to longevity, there are often concerns over the quality of the last few weeks or months of life.

This piece by Atul Gawande in the New Yorker last month provides a set of examples that elucidate many of the issues facing doctors and patients in decisions on end-of-life care.  Obviously, it is difficult to develop a set of rules or guidelines for how care should proceed in such situations, but a recent study on palliative care sheds some light on the effectiveness of new techniques for dealing with the issues unique to dealing with one’s ultimate fate.

Clearly, given the amount of resources expended on care at the end of life (Spending by Age (pdf),  Spending by Percentile (PowerPoint slide) and Medicare spending (pdf)) as well as the reality that an increasingly large share of the population will pass through the Medicare system over the next several decades it is imperative that serious discussions about these issues.  The recent efforts at health care reform proposed for Medicare to provide reimbursement to doctors for having discussions with patients about end-of-life care issues and options.  These proposed policy changes were construed as promoting ‘death panels’ to some which was an unfortunate diversion from the serious discussion that needs to take place, both between patients and providers and at the national policy level.

Any solutions to the problems that the health care system faces in providing cost-effective and desirable health care at the end of life are not easy or obvious.  But the need to search for courses of care that meet patients’ (and families’) desires while providing care that will not further strain the already bleak financial outlook for Medicare seems obvious.

So, any thoughts on how to confront this issue are most welcome in the comments.

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