As a Life Ends, Do We Treat the Patient or the Disease?
End of Life Discussions Should Consider More Than the Financial
By George Martin, MD – Senior Medical Director for Health Integrated
“No one wants to die. Even people who want to go to heaven don’t want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life’s change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true.”
– Steve Jobs Stanford Commencement Address Spring 2005
In 2009, total expenditures for Medicare were $2.5 trillion. That same year, the Centers for Medicare and Medicaid Services (CMS) estimated that 25% of those costs were spent on end of life care. Over 10 years, reducing end of life costs by 50% would reduce the expenditures by approximately $3 trillion. Yet we fail to use available resources to advise patients and families when the obvious end is near.
A plethora of resources exist from social work to hospice to assist with end of life decisions, but the common starting point is with the attending physician. And the physician has no skill at this. How much sadder we must make patients and families by not appropriately adjusting their expectations. But we neither train for the skill nor support the skill when used. It seems that we are wonderful at treating disease but not well equipped to treat patients.
To treat patients requires knowledge of their needs and desires, empathy and training. But physicians are trained to treat disease and we are not trained to assist with the big questions. Who takes the lead on asking what the point is to end stage care and when does that conversation take place? End stage disease comes for various organs. Heart failure, Alzheimer’s, ESRD and ESLD patients may have their lives extended. When do we take them into our confidence and allow them to know that they are not going to get well? The answer is almost never because we are so focused on treating disease.
Here, then, is another critical transition. Based on the preceding blogs, we decided that communication and handling transitions appropriately is critical. This next to last transition, the last being to the undiscovered country, must be done by the medical profession. If we do not,the work will be done for us and likely, not by those with the most knowledge. Good care coordination will preserve choices for patients and families. Poor choices will result in central governmental planning that will be one size fits all and rigidly applied. See above for the dollar value of limiting end of life choices.
Transitions to end of life choices are not easy. People are dysfunctional and families differ on choices. If this transition was easy it would have been accomplished.
What do you think?
Thanks in advance for your input. You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.
George Martin, MD
