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A More Painful, and a More Expensive, Death

Friday's Washington Post has an excellent editorial on end-of-life counseling. Toward the end, the piece touches on some actual evidence that individuals who have clear end-of-life directives live just as long as those who don't but spend 36 percent less in their final week and they have a better quality of life. The Republicans demonizing this policy — most of whom supported it previously — are consigning individuals to a more painful, and more expensive, death. That sort of language feels exaggerated, or inflammatory. But it's not. It's just what the evidence shows:

As it happens, there is evidence, though inconclusive, that advanced directives might save some costs. A study of 603 patients with advanced stages of cancer, published this year by Harvard researchers at Dana-Farber Cancer Institute, found that the final week of health costs for those who had discussed end-of-life treatment with their doctors was 36 percent lower than for those who did not have such talks.

But here's the more important finding: Patients who hadn't discussed treatment options did not live longer, but they had a "worse quality of life" in the final week, more likely to be in intensive care or on a ventilator. Yet a recent AARP survey of people 50 and over in Massachusetts found that, though 89 percent of seniors believed it very important to get honest answers from their doctors about end-of-life issues, only 17 percent had discussed such issues with their doctors. Indulging in demagoguery on this issue — suggesting, for example, that encouraging physicians to discuss advance directives with their patients is starting "down a treacherous path toward government-encouraged euthanasia," as House Minority Leader John Boehner (R-Ohio) asserted — could have the effect of consigning more patients to unnecessarily uncomfortable deaths.

By Ezra Klein  |  August 14, 2009; 12:05 PM ET
Categories:  Health Reform  
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Comments

This is certainly true, and why people such as Sarah Palin have supported advance directives in the past. But scoring political points at the cost of creating greater suffering and expense down the line is just par for the course for today's GOP, exemplified by Chuck Grassley.

Next they are starting on killing climate change, I read, through the same bullying and big lies.

I never thought I'd say this, because for most of my life I felt things were generally getting better, sometimes much better, but I'm glad I'm 66 and not 26. And even though I spent my working life as a public employee so I enjoyed government-provided health care and now have a pension and mmedicare, I do support both significant reforms and a more equal tax system to benefit younger and less well off people.

Posted by: Mimikatz | August 14, 2009 12:19 PM | Report abuse

It may not be generous of me, but the more this lunacy goes on the more I'm inclined to support lingering, high-intervention, painful deaths for the people who believe the "death panel" BS. Far be it from me to deny them the 'heroic' measures they consider essential.

Posted by: latts | August 14, 2009 12:30 PM | Report abuse

there's that "evidence" thing, again. If you're relying on stuff like that, you'll never understand these town hall disruption folks.

Posted by: bdballard | August 14, 2009 12:38 PM | Report abuse

It is good that WaPo Editorial is taking on this issue, though I do not agree with their contention.

The reference number is $90 Billion over ten years for end-of-life treatment which can be saved by, in Palin language, ‘pulling the plug on Grandma’. Now knowing how Dems are struggling for every dollar in financing the coverage expansion, this is a big amount.

The issue with the editorial is that, it attempts ingeniously to undermine the cost saving motivation in curtailing avoidable end-of-life treatment. In a perfect world where USA is that 'land of chosen' by Almighty, USA Government indeed can be open ended in underwriting expenses of each and everyone all the time. The small problem is not only Washington DC is not that shining city on the hill, we have federal deficit of the order of 2 Trillion Dollars. Whom are you trying to fool here that 'it is not the saving' motivation here? Why not? In given circumstances, I would expect our government to talk nothing but saving and addressing deficit.

The larger issue is, USA Government is not appointed by Almighty so that it takes the heavy duty of 'saving Americans life from illness'. It is just an administrative contraption, elected by people, to collect, secure and distribute Medicare Tax Dollars. Anytime our law makers leave this specific 'sense of what our government is'; we have a problem.

And that is the real answer to Palin's of this world - Government of USA is not in the business of defining Morality or undertaking Moral activities (beyond a limit). It is in the business of simply distributing Medicare dollars judiciously which can mean 'pulling the plug on Grandma' when the chord is public money.

Republicans can argue that they do not want this saving to come out and then be transferred to increasing coverage. No doubt it is a moral choice – ‘moving Grandma’s dollars to Trig the kid’. Because of this it is much better to present these as two separate political decisions – one saving costs and next using those savings to expand coverage. The battles are different. Obama might have come to the first battle because he wanted to win the second battle initially. But, he has to understand winning the fist battle is in itself important and worthy enough achievement and it need to be cluttered or mixed by happenings of the second battle.

Posted by: umesh409 | August 14, 2009 12:47 PM | Report abuse

"But, he has to understand winning the fist battle is in itself important and worthy enough achievement and it need to be cluttered or mixed by happenings of the second battle."

Correction - But, he has to understand winning the first battle is in itself important and worthy enough achievement and it need not be cluttered or mixed by happenings of the second battle.

Posted by: umesh409 | August 14, 2009 12:57 PM | Report abuse

Focusing on quality of life is the key here. I cared for my father part time at home until he died. We had a living will that included not transferring him to a hospital or doing any invasive care, but rather to make him as comfortable in his own home as we could during those final months, with the able and loving help of the local hospice. He may have survived another 6 months in a hospital/ICU at a high 6 figure cost, but he would have been miserable and disoriented all the time he was there instead of being in familiar surroundings with loving caretakers easing his pain and comforting him. He died in his sleep, peacefully and without the panic, lights, commotion, or anguish of being hooked up to a ventilator, IV, and feeding tube or heroic efforts to revive him. A very dignified way to pass on. End of life counseling would make this a more likely outcome for other terminally ill or old (my father was 83 when he died) people and is an end in and of itself. The fact that his decision to die at home saved medicare $100,000-600,000 in end of life care is an added bonus to his peaceful passing.

Posted by: srw3 | August 14, 2009 1:00 PM | Report abuse

All well and good, but the issue is not essential to reforming the health insurance system. Make end of life counseling into a "concession" for now, try to get some mileage out of it, and get it into its own bill later -- the Seriously Not Death Panels Okay Act of 2009.

Posted by: TheodoreLittleton | August 14, 2009 1:00 PM | Report abuse

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