In its new report, "Dying in America," the Institute of Medicine takes a critical look at our flawed American medical system that makes end of life care both expensive and contrary to patient's wishes. The report states:
"Current financial incentives encourage a reliance on acute care settings [hospitals] that often are costly and poorly suited to the needs, goals, and preference of patients and their families. The committee recommends a major reorientation of payment systems to incentivize the integration of medical and social services, the coordination of care across multiple care settings, and the the use of advanced care planning and shared decision making to better align the services patients receive with their care goals and preferences." The paper further concludes:
"The committee finds that a palliative approach typically affords patients and families the highest quality of life for the most time possible."
A large part of my book is devoted to the futility of aggressive care at the end of life, especially in the frail elderly. Contrarily, palliative care, in which a person's comfort is emphasized more than is number-fixing and excessive testing/treating of ailments, leads to better outcomes in terms of quality of life and, very often, length of life.
In addition, a vast majority of elderly people, when asked, prefer a palliative approach, especially if it can be delivered in their own homes.
Then why is so much of end-of-life care for the elderly provided in a hospital, often an ICU, with a futile assault on disease and illness that can lead to nothing more than the outcome of painful deaths and escalating costs?
Simply put, Medicare does not pay for a more humane approach. While it does finance hospice, only after doctors can certify that patients are going to die soon, it does not pay for palliation in the frail elderly who do not necessarily have any specific diagnoses that indicate their deaths are imminent. Even under hopsice, Medicare finances very few services that allow frail elderly to remain at home. When an older person gets sick, Medicare pays for the hospital, and if they can stay three nights, it pays for rehabilitation. Very often this is the only avenue that patients and their families can afford, and too frequently it leads to a brutal, costly death within the walls of a medically aggressive institution. While most ill elderly patients and their families prefer to remain home, Medicare will not pay for nursing aides, certain medical treatments, and virtual doctor visits that would make such a situation possible. If we look at the problems of dying in America, we do not have to look much beyond the rules and payment structures of Medicare. Rather than follow a path that allows for palliation under a patient's own roof, Medicare has veered along a precarious cliff in which it pushses patients and families to a place they do not want to be and for which Medicare and society have to pay a huge and unnecessary price. No current reform efforts truly address this fundamental problem. Perhaps with the new report being published, we can at least start talking about it.