End-of-life care requires national dialogue


Chronically ill patients in last years of life account for 32% of total Medicare spending.

By: John E. Schiller, Esq.

Our healthcare delivery and finance system spends an enormous amount of money providing medical care (not palliative care) in the last year of life. Although it is the third rail of healthcare reform, it must be discussed. Policymakers do us a disservice by pretending that it’s an issue that can be put aside. Unfortunately, chants of death panels all but silenced any meaningful effort to address this important topic. 

By all accounts, a meaningful portion of healthcare spending is for care of some kind during the last year of life. In fact, according to the Dartmouth Atlas of Care, patients with chronic illness in their last two years of life account for about 32% of total Medicare spending. This is only one of many studies that documents the large expenditures being covered for care of patients in their final days.

These numbers scream for a national dialogue about what medical care is owed to people who have reached an age when they face chronic medical maladies that require expensive treatment and often involve hospitalization and secondary illnesses, such as infections. What care is given in the last year(s) of life; who should decide what care is appropriate; how such care should be delivered; and who should pay for it are all questions that policymakers and citizens need to think about and act on if we are to strike a fair balance in end-of-life care. 

It’s wrong for the aged to die in hospital beds after suffering medical interventions that, in the end, cannot stop the inevitable. Or worse, die from painful infections picked up in a hospital. 

For most people, the cost of end-of-life care for the elderly is paid for by a third party, and there is no real financial cost to the patient or his or her family. Given the enormous pull of wanting the patient to stay alive, no effort is spared-whether it makes the patient more comfortable or not.

Health reform’s effect 

Although the Affordable Care Act does establish palliative care as an essential health benefit that must be covered by all insurance plans subject to the law, each state can decide how to meet this requirement and how, or if hospice will be a covered service. This presents a good opportunity for stakeholders in each state to address a number of important policy issues including the following:

  • The purpose of medical treatment and intervention;

  • The cost of alternative approaches to care;

  • A patient’s right to die with dignity;

  • The role of nurses and nurse practitioners;

  • The role of hospice and palliative care; and

  • The role of family and other caregivers.

Many studies and reports contain not only objective data that must be considered, but also a host of important subjective observations and suggestions. End-of-life care in other countries offers helpful insights that are also worthy of study. Hopefully this subject will get the attention it deserves and policies will be refined and developed that will move our country forward to a more sensible, consistent, compassionate and cost-effective approach to end-of-life care.

Schiller is a partner and head of the Health Law Practice Group at Cleveland-based Walter | Haverfield LLP.

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