Americans are legend for their discomfort in discussing death. That makes conversations about end-of-life care a big challenge, even though the medical attention paid to the dying can drive up health care costs. A quarter of traditional Medicare spending for health care is for services provided to program beneficiaries in their last year of life—a proportion that has remained steady for decades. But new studies shed interesting light on the end-of-life experiences of patients with cancer, as well as how physicians themselves spend their last days. And it is worth watching how California grapples with the tough issues tied to doctors’ roles in assisting the dying in ending their lives.
Let’s look first at the provocative, published findings of an oncologist and a radiation oncologist about aggressive care for those with late-stage cancer. The researchers compared U.S. patients with patients in other countries. They focused on cancer because, “in developed countries, it is the second leading cause of death and the most expensive per patient.” The researchers found that just under a quarter of Americans with cancer die in hospitals — a lower rate than occurs in Canada, England, Norway, the Netherlands, Belgium, Germany, and six other industrialized nations they studied. Further, as they wrote in a New York Times Op-Ed:
America was not the most expensive country in which to die. On average, $21,840 was spent on the last six months of hospital-related care for dying cancer patients in Canada and $19,783 in Norway. In the United States, the bill was $18,500 per patient. (That figure does not include physician costs, which are part of hospital spending in other nations. Including them brings America’s costs up by about 10 percent, leaving us still below Canada and about equal with Norway.)
Americans, in the researchers’ view, did less well in admitting cancer patients more often than others internationally to costly intensive care in the last six months of their lives. Americans also received more chemotherapy than their global counterparts late in care when it’s unclear if it benefits the gravely ill.
As I have written, it is important for all of us to plan and to let loved ones know how we wish to be cared for when we are dying. The reseachers urged that physicians be more candid about prospects for the sick. They called for more palliative care and hospice resources. They found this nation making progress in confronting the chilling silence surrounding our deaths and the costs of end-of-life care. This led them, too, to question whether such care — as opposed to fee-for-service medicine — plays as significant role as it might seem in increasing health costs.
Families, by the way, appreciate when relatives with late-stage cancer and Medicare coverage get enrolled earlier in hospice care, other research shows. They also perceive that end-of-life care is better when physicians avoid admitting sick kin into ICUs within 30 days of death, and help the gravely ill die outside of hospitals.
Just so you know, while many of us would prefer to die at home, surrounded by loved ones and in comforting surroundings, most of us (72%) die in a medical facility of some kind, other new research finds. But slightly fewer health care professionals (63%), especially physicians, die in medical facilities, meaning more died at home. The researchers didn’t say why. They speculated that physicians may be more aware of life’s limits and reluctant to receive aggressive treatment in institutions where they have worked for most of their lives. The lead investigator made this key observation: “I think [that] even if the people who should be the best at this are still not dying in the comfort of their home that we still have a lot more communication and understanding of medical options to get more people to die a ‘good death.’ ”
In the Golden State, the terminally ill, their families, lawmakers, and caregivers are struggling to determine how medical personnel should assist with “good death.” With the reluctant assent of its governor, a one-time Jesuit priest in training, California last fall became America’s fifth state to legally permit physicians to assist dying patients in ending their lives with medication. The California Medical Association recently has issued guidelines to doctors about this topic. The 15-page document addresses the array of moral, ethical, and professional issues that the doctors’ group insists practitioners should consider. News reports make the point that Catholic hospitals will not allow physicians to assist patients in ending their lives in their institutions.