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The politics of dying: part one

Adam Newman | Tuesday, January 29, 2013

Two things are promised to every person: death and taxes. While most op-eds would focus on the second of these two, I am going to focus on the first: death.

Most Americans believe it is a moral obligation for our country to provide health care at the end of life for the elderly, even at an immense cost. Medicare, the government insurance program for the elderly, spends roughly 30 percent of its budget on care in the final year of life. The amount that we spend on end-of-life care will quickly increase in the future due to the aging of the population and the unsustainable rise in per-capita health care costs. As I have written before, America’s long-term debt is driven by health care costs, especially through Medicare. If America wants to address its long-term fiscal health, it has to address health care costs. If America wants to address health care costs, it has to address end of life care.

The very suggestion of curbing the amount that is spent on care at the end of life angers many. Every person will lose loved ones sometime in their life, and to think that their loved one will not receive necessary care is unfathomable.

However, as counterintuitive as it may seem, costs at the end of life can be brought down while simultaneously raising quality. One has to understand that the American health care system is a patchwork of providers that have no incentive to coordinate and are reimbursed based on the quantity of services rendered, not the quality of outcomes produced. Roughly seven in 10 seniors die from a chronic condition, such as heart disease and cancer. These diseases require many different doctors, treatments, tests and drugs. However, when doctors do not coordinate and have the incentive to utilize many tests and services, the consequence is that seniors undergo costly and expensive care at the end of their life, prolonging suffering and discomfort, while oftentimes ignoring the senior’s preferences for their final weeks and days.
Not only do seniors receive poor quality care at the end of life, but they also do not die in their preferred setting. According to the Dartmouth Atlas, 55 percent of the patients who prefer to die at home surrounded by loved ones still die in the hospital. This phenomenon occurs for three main reasons. The first is that fee for service reimbursement creates an incentive for doctors to keep people alive longer and conduct unnecessary and expensive tests and procedures. At the very worst, some doctors are trying to make more money by keeping these patients as long as possible. At the very best, doctors are simply doing what they are trained to do: keep people alive, but without any conversation as to how the patient wants to die.

Second, family members are usually, and understandably so, unwilling to let their loved ones die. Family members usually are in no state to make decisions about the end of life, and usually do not understand how their decisions could hurt their loved ones through painful, invasive, unnecessary medical care. Oftentimes, people are unable to let their loved ones go, and demand every medical intervention possible without realizing the care they want may have no benefit and can lead their loved one to suffer.  

Finally, patients are also part of the problem. Even for those who believe in an after life, death is scary and we usually prefer not to discuss it. Thus, when we are in a situation where we cannot make decisions on our own, it is up to the family members and doctors to make it for us.
Ultimately, the way to lower costs and increase quality for end of life care is to reimburse health care systems, such as Geisenger, to guide seniors and their families through the final years of life by having conversations as to how the senior wants to die, working to coordinate care to avoid unnecessary suffering, and ultimately working to ensure that seniors’ preferences for their final months, weeks and days are fulfilled. This helps prevent unnecessary invasive procedures at the end of life while allowing seniors to die in peace and dignity.  

However, the destructive nature of the politics of health care, especially related to end-of-life care, make reaching this point politically impossible. In my next article, I will explain why.  
 

Adam Newman is a senior political science major. He can be reached at anewman3@nd.edu

The views expressed in this column are those of the author and not necessarily those of The Observer.