Medicare Supply of Medical Services

Medical Conservatism and End-of-life Decisions

The New York Times Magazine discusses two pressing issues: 1) what type of treatment to the elderly really wish to receive at the end of their life and 2) how does economic incentives affect how physicians advise these patients.  Much of my own research has dealt with (2) [see here].  The following two excerpts are revealing.

According to an analysis by the Dartmouth Atlas medical-research group, patients are far more likely than their doctors to reject aggressive treatments when fully informed of pros, cons and alternatives — information, one study suggests, that nearly half of patients say they don’t get. And although many doctors assume that people want to extend their lives, many do not. In a 1997 study in The Journal of the American Geriatrics Society, 30 percent of seriously ill people surveyed in a hospital said they would ‘rather die’ than live permanently in a nursing home. In a 2008 study in The Journal of the American College of Cardiology, 28 percent of patients with advanced heart failure said they would trade one day of excellent health for another two years in their current state.

It was a case study in what primary-care doctors have long bemoaned: that Medicare rewards doctors far better for doing procedures than for assessing whether they should be done at all. The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way.


  1. I think it comes down to the patient to really request and demand the information from their physician about pros/cons/alternatives and take a stand on how they want to be treated at the end of their life. Is the reason that patients are responding to the polls, indicating that they aren’t getting all the pros and cons really the physicians problem? I don’t think we can blame it all on the physicians. No matter what, there will probably always be financial incentives to provide care and more of it than necessary, it’s what they do, and it’s how they get paid. Is that why the Doctors aren’t telling their patients about the alternatives and giving them the full pros and cons? I hope not. I hope that they are at least thinking that they are more qualified to make the correct decision, either way, I don’t agree with either the doctors thinking they are in the position to make decision for the patients, especially if there are financial incentives for them. The only way i would think to get around this over treatment would be to shift the financial incentives to other aspects of healthcare, specifically not over treating. Healthcare is a business, maybe Medicare needs to change the way it reimburses physicians for end-of-life care. Overall, something needs to be done about it.

  2. In the death-certificate study, 57% of all deaths had been preceded by a decision to forgo life-sustaining treatment; this decision was accompanied by the administration of potentially life-shortening drugs to alleviate pain or other symptoms in 23%, and by the administration of drugs with the explicit aim of hastening death in 8%. A drug was given explicitly to hasten death to neonates not dependent on life-sustaining treatment in 1% of all death cases. No chance of survival was the main motive in 76% of all end-of-life decisions, and a poor prognosis was the main motive in 18%. The interview study showed that parents had been involved in making 79% of decisions. The physicians consulted colleagues about 88% of decisions. Most paediatricians favoured formal review of medical decisions by colleagues together with ethical or legal experts.

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