Speaking about which services hospitals and doctors should provide at the end of a patient’s life is always a sensitive subject. Family members become emotional and desire any procedure which has a non-negative chance of prolonging the patients life, regardless of the cost. This is what insurance is for, to safeguard families from calamitous medical conditions. Having the end of life procedures covered by insurance, however, means that many unnecessary services are being provided. The Associated Press gives an example in the case of cancer patients (“Cancer patients, doctors don’t know when to give up“).Â
Overly aggressive treatment gives false hope and puts people through grueling and costly ordeals when there is no chance of a cure, cancer specialists said.
     âThere is a time to stop,â? said Dr. Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical School. âItâs sometimes easier to just keep giving chemotherapy than to have a frank discussion about hospice and palliative care.â?
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After examining over 200 thousand Medicare medical records of cancer patients who died in the 1990s, Dr. Earle found ICU visits in the last month of life climbed from 8% of patients in 1993 to 11% of patients in 1999, although the number of patients visiting hospice care facilities in the last three days of life increased 3 percentage points as well. Even the president of the National Coalition for Cancer Survivorship said:
âI see, in cancer care, so much treatment being used in the last three months of somebodyâs life that doesnât really help.”
Mandating what care patients should have is not desirable. Doctors should take into account the cost of procedures when they preform them; however as the system is currently set up, physicians have no incentive to reduce costs (except maybe in HMOs).  This is a problem for which I currently have no good solutions. Any suggestions?Â
“Any suggestions?”
Yes. The UK uses QALY metrics to systematically ration expensive care, especially at the end of life. I believe their current threshhold is 50,000 GBP per QALY (quality adjusted life year). It the U.S., we would probably opt for a somewhat higher threshhold if we moved in that direction, but I think the approach makes sense. If the treatment is more expensive than the QALY standard allows, insurance would not pay for it, but the patient could self-pay if the resources were there and that is what he or she wanted. The standard would have to differ somewhat by region to account for differences in wages and other costs of providing care.
Second, my understanding is that currently only 30% of Americans have executed living wills or advance directives for healthcare. I see no reason why we could not drive this number up a lot with some effort. Perhaps executing a living will could be made part of the process of signing up for Medicare or Medicaid or a requirement upon or shortly after entering a skilled nursing or assisteed living facility.