Why Medicare spends so much money on the last year of life - a little insight.

[hedgehog]

A year ago, my mother started to fail. For whatever reasons, she wasn't making red blood cells. Over the last year of her life, she had several hospital admissions. She began her last week in an ICU, and was moved to a regular room at the family's insistence when she indicated she was done with heroic measures. Now my MIL is starting down the same path. She just had a pacemaker installed. I'm uncertain whether this has done anything at all for her longevity or quality of life. We need better data on the benefits of such interventions so we can make better decisions. Not I said benefits, not cost vs benefits. It isn't about the money, or isn't only about the money. It's about the people.

[Hestia]

1. PBS has a Death & Dying series that addresses this very issue. Generally it is because

the families don't want to appear to be a death panel and tell the doctors to do whatever they can to save the person. There are over 18,000 people on respirators in this country costing billions of dollars to keep "alive". Even a willing will cannot help in some cases. If you are put on a respirator when you arrive at the hospital, no one wants to take Granny off of it. We need better Palliative Care issues in this country.

[hedgehog]

2. I think my family had a good feel for what was possible and what wasn't -

plus my mother told us she'd heard the banshee, so we were confident that the time had come.(how's that for a blend of good education and traditional belief!) My husband's family has a love/hate relationship with medicine - they're suspicious of doctors doing anything, but at the same time want the doctors to do everything. The next days, weeks or months are going to be both very difficult and very expensive, I'm afraid. It's a very complex issue with no easy answers, but getting more info about outcomes is a good start.

[WCGreen]

4. As someone who could very well be making that decision about myself

in the near future, I watched a show on PBS about the end of life care.

I've given a lot of thought about it.

If there is no chance of getting better just a slow degeneration, I would like to hang on until I get to the stage when I can't function reasonably. I have yet to define for myself what that means, but I have been thinking seriously about what I want.

[hedgehog]

8. There was an excellent article in the New Yorker a year or so back on this issue.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

[lapislzi]

20. OMG, that was a hard read.

Makes me glad my husband, daughter, and I have discussed these issues and made our priorities clear.

[WCGreen]

22. Thank you....

The progression of the fail is what I am worried about. I have already suffered horrible pain and debilitating breathing problems...

I like what the old man said. If I can eat Chocolate ice cream and watch football, I want to live...

I am seeing my GP next week. I am going to start the conversation then.

[JDPriestly]

23. Prepare a health directive so that your children to not feel guilt

when your time comes.

And sons and daughter -- talk to your parents about what they want you to do in the event of a serious health issue or injury. You might be surprised at the number of elderly people who really don't want to live their last years or months as expensive vegetables in hospital beds.

[hedgehog]

26. Single adults need to have a designated proxy or even someone who

can talk to the doctor when they are sick. Once you turn 18, your parents have no legal right to your medical information. That's fine if you don't get along with your parents, but there should be someone who can watch out for you if you get sick or hurt.

[boston bean]

3. The only discussion should be between the patient and their doctor.

if your mother n law wanted the pacemaker, who is anyone to judge.

That is until they are unable to make these decisions.

[hedgehog]

5. I'm staying out of any discussion, and I agree that the decision

has to be between patient and doctor. I'm just advocating for better information to be out there for people having to make decisions.

My mother had a masectomy two years before her death. I wish we knew for sure that'd been necesary - it caused her a lot of grief and pain. If we'd known for sure that the tumnour was fast growing, then we'd feel better about the surgery. It's the niggling question of what if - what if her heart would have failed before the tumor caused any issues?

For my MIL - the question is whether or not the pacemaker makes any difference given her other issues.

[boston bean]

6. you wouldn't know. So it's really a moot question for you, as you are not the patient.

You can question these things for yourself all you want.

Leave others with their choices.

[elias7]

14. Unfortunately, it's not really that simple

Elderly patients with diminished mental faculties look to their family members for guidance with decisions. I certainly would get input from my family on serious matters, especially if I had no real idea what these things entailed. Who here really knows what a pacemaker is, what are the indications for implantation, what are the potential complications, what does the surgery involve, what are the medical alternatives, what are the consequences of not doing it...That's a lot to process if your Cardiologist has the insight to answer the questions you haven't even thought of to ask.

In my experience, the patient or the DPOA is in charge of decision making, but asking questions and providing input is not at all a moot point; rather it is part of the process in most people's decision making...

[boston bean]

17. I already clarified that above, in my conversation with the other poster.

That is unless someon cannot make those decision for themselves.

OTOH, it not my business, or anyone elses, nor is it a judgment that anyone has a right to make, regarding others healthcare decisions. For all we know they were well aware.

You yourself as a patient or a healthcare proxy for someone, has every right to inquire and make your decisions. It is not your right to tell others how to make theirs.

[elias7]

30. In reality, many mentally competent people seek the opinions of family in these matters

I'm not talking about those with advanced dementia or brain damage from strokes or other cases where there is a DPOA. You say it is not your business, that it is a judgment no one else has a right to make, but what if your spouse or your parent or sibling NEEDS your opinion and input, because the choices are too overwhelming? As a physician, I see this a lot. My only point is that if you have not been in that situation before, it is easy to take a purist attitude, but in fact, there's a lot of gray area here.:)

[w8liftinglady]

9. I see that decision made daily

...and it's a tough one.Every case is different.In my mom's case,treating her breast cancer has given her three more years.On the other hand,I take care of vent-dependent patients begging to be let go.It definitely is a doctor-patient open discussion.

[treestar]

7. Tough issues

YOu get the "death panel" crap from the right immediately

Modern medicine is at fault - it has its good points. But it sure obscures the meaning of death. Say in the 19th century, people would die like a week earlier than they do now, due to inability to keep them alive or the next week or so - all made possible by advances in medicine.

[madrchsod]

10. i had to tell my sisters that our mother who just had a stroke..

had only a few months to live due to her lungs would shut down in the next few months. we decided that any procedure to save her life would be cruel and futile. the worse part of this is she had already went into the light but it took 3 days for her body to die.

my dad was offered a few more months to live but at a cost of thousands of dollars(which was covered) but my mom and dad decided it was`t worth it.

when ever the right wing assholes brought up the "death panels" i would have liked to ask them if they went through the same thing as my family.

[snooper2]

11. My FIL is going to go any day now...has been in ICU for 4 weeks

on Medicare...

Since February he has spent 90% of the time in either the hospital or hospice. He's been on a colostomy bag for six months, liver, pancreas, heart, lungs, kidneys- they have all been shutting down for a while.

On Monday the doctors asked if we wanted him put on life support. Talking to my wife we are like, whtat the hell? Just laying in a bed with sores all over unable to communicate hooked to machines. What kind of quality of life is that? At this point when he does open his eyes they are already rolling back :(

[joeglow3]

12. In many cases, we treat our pets better than our relatives

This is THE discussion needed when discussing rising medical costs. However, as pointed out above, you cannot have an honest discussion about it because the right, looking to capitalize, will just scream "death panels."

[ehrnst]

15. It seems easier to spend money prolonging death than it does to provide basic care for all.

We are so squeamish talking about death, we avoid it at all costs. Just because we have the ability to keep barely conscious, dying people breathing for few more months doesn't mean we're doing them any good.

And what is the cost - in many ways - does this prolonging of death to the rest of society?

[hedgehog]

16. Again - I think the issue of money complicates an already complicated situation.

Put the focus on quality if life and answering the question of when it's time to let go, and the money issues will resolve themselves. I mentioned money in the OP because that is a common charge made about Medicare - that a large portion of the money is spent on the last days. It stands to reason that costs go up when the patient is deathly ill! I think that people need a better understanding of options and outcomes. The very procedures that run up costs may be ones that people don't really want.

[CanSocDem]

19. Indeed.

"Put the focus on quality if life and answering the question of when it's time to let go, and the money issues will resolve themselves."

The 'quality of life' aspect is the most important. My parents lived a very full life and when my mother was admitted to the hospital in her 90's, we, as a family, had already discussed the Do Not Resuscitate issue. Neither of them wanted to spend their final days hooked up to life support and prolonging the inevitable. It was a sad day but she rallied and lived another 5 years.

It wasn't a question of money, but your point is well taken. The issue was about quality of life. Both were fierce Christians and probably had some fears about the afterlife. Never-the-less, when their time came they were adamant about not wanting to linger.

As the sibling charged with watching over them in their last few years I may not have been the best choice as I am equally anti-religious and anti-medical. I believe in the individuals right to choose and believe they choose when to die. So I accommodate their choices to the best of my ability. Having had the earlier discussions it was easy to let them go when the time came, despite the medical industry's eagerness to intervene.

.

[woodsprite]

13. My mom had disseminated intravascular coagulation (DIC)

Transfusions were what was keeping her alive and they couldn't find the root cause for the DIC. Her blood would clot, then the clots would break up but be unusable as a blood product by the body. My brother and I had to make the decision to stop the tranfusions and allow her organs to complete the failure process. That was the most difficult decision I've ever had to make. Mom was awake and aware. We could have had insurance pay for another week or two of the transfusions, but with no diagnosis found of an underlying cause (even after all the testing and calling in specialists from Johns Hopkins), I don't think it would have made any difference.

[boston bean]

18. I'm sorry that must have been difficult.

if your mom was awake and aware, was it she that actually made the decision?

[Xithras]

21. It should never be about the money.

It should always be about what the patient wants. If a $100,000 surgery will only buy them six months, then give it to them if they want it. To oppose that is to put a pricetag on the value of a human life.

[hedgehog]

25. I think the money issue complicates things because the focus should be

on the individual person and what they consider to be quality of life. One person wants to be able to walk and take care of himself, another may be happy as long as they can sit up and watch the football games. We need to be able to talk about this with our doctors, and they need to have some answers to give us. For example, a cardiologist may be able to tell you that a pace maker would keep your heart beating properly. He may not have any idea of whether you'll ever be well enough to get out of the hospital bed. One person may want an extra two weeks of life on that basis, another may not. The problem is that right now I think the doctors don't have the info they need to give us so we can make the right decisions.

[Zoeisright]

29. Sorry, you're wrong.

Medical ethics demands that healthcare is rationed in some way. Right now it's rationed in dollars. If you can afford healthcare you can get all the healthcare you want, even if it does nothing. We need to start balancing quality of life and efficacy of treatment, like other countries do, along with lifespan. Wasting millions of dollars at the end of life just so someone can live a bit longer, while children die from treatable diseases is despicable.

[dembotoz]

24. i can see how it happens my mom is over 90 and has been in the hospital

for 1 week on 2 occassions in the last 3 months

prior to that she could count her total hospitalizations on one hand--and that included her birth and mine.

before they die--and i hope for my mom it is not anytime soon.....
they get sick

healthy people don't usually die
sick people do.

[hedgehog]

27. Here's another comment on this issue:

"Above all, age is the wrong criterion. The capacity to recover and return to a meaningful life is the proper criterion."

http://www.cnn.com/2011/11/04/opinion/etzioni-elderly/index.html?eref=mrss_igoogle_cnn

[davsand]

28. I think a lot of families are reluctant to let go.

My Dad suffered with heart disease for over a decade. He endured multiple open heart surgeries along with countless stents. Finally, he got to a point that the Docs at Mayo told him that there was nothing more to be done other than medications--which were ultimately going to stop working when his heart function declined enough. He came home to die.

The first couple years went by with one or two trips in to the hospital to drain fluids off (with congestive heart failure the fluids accumulate in your body. You, essentially, drown in your own fluids...) He'd be in a few days and come home about 40 pounds lighter with all the accumulated fluids removed. The Docs would tinker with his diuretic scripts a little bit and send him home.

The next year or so, the trips to the hospital got more common as the diuretics became less effective, and his kidneys began to fail. He began to carry extra fluids all the time, and he got to the point that just walking to the bathroom was a major undertaking. Walking across the room became such an issue he needed a walker. He started to fall down and not be able to get back up. My mom would call me in a panic, and then my husband or I would run over there and help get him up off the floor...

Finally, it got to the point that he simply could not function any more. He passed out one day in the car on the way to the Cardiologist and ended up in the ER, instead. He never went home again, and three weeks later we had to make the DNR decision.

Every step of the way, we were looking at what would make him comfortable and what did he want/choose. When his kidneys shut down and he was in a coma, we knew there was no coming back from that, there was no hope of him being able to do much of anything except lay in a bed and have air pushed in and out of his lungs by a machine. We cried together, and made the decision to work with hospice--to take away the machines. That was four years ago this next March and I still cry when I think about it.

I have no doubt that we made the right calls at the time, but I also can see how somebody from the outside would look at this all and think we were wrong in one or another decision we made. We were reluctant to let go, but we also were reluctant to put him (his body, really) through any more than it had already endured.

There is no way to look at this issue without emotion, nor is there any way to approach it with an attitude of "cost savings" or "benefit analysis." This has got to be all about the patient and the family.



Laura