"End of Life" Care Costs: A Logical Fallacy

A joke:

Man gets on a bus in a strange town and asks the kid sitting next to him, "Which stop is Main Street?" Kid answers, "It's three stops before I get off."

An assertion:

More money is spent on medical care in the last year of life than at any other time (implying wasted resources on futile care.)

This statement may be true, but those who would then try to discuss means of decreasing this amount are losing sight of a critical distinction: the "last year of life" is a retrospectively defined time frame. And as the vast majority of oncologists will affirm, it is devilishly difficult -- if not impossible by definition -- to pin down that designation reliably in a prospective fashion.

I don't disagree that futile care is a huge problem in this country. Perhaps measures such as default DNR status for nursing home patients, or even more proactively, a prohibition on admitting them to an acute care facility might put a dent in the sum expended. Even if we were better able to address the unreasonable expectations of the families of clearly terminal dementia patients (thus eliminating all those "senile grannies" that seem to be the bane of existence for Panda, White Coat and the Happy Hospitalist) I don't think we'd see much of a dent in those dollars; at least not nearly as much as many professionals in the acute care setting seem to think we would.

However you look at it, most people get sick before they die. (Though I'm reminded at this juncture of Health Business Blog's David Williams' pithy comment, "For all its disadvantages, sudden death is cheap to treat.") When they get sick, they go to doctors (NOT always to emergency rooms, believe it or not.) Doctors then try to figure out what's wrong; this often involves testing, imaging and consulting with other doctors. When a diagnosis is made, especially a serious one, treatment is then undertaken. Costs for treatments like surgery, prescription medication, various therapies and so on add up quickly. By the time it becomes clear (perhaps) to some or all involved that the patient is not going to recover from the condition, the expenses have already been incurred.

Not only that, but patients often get well. Treatments sometimes work. Most of the time it is not possible to tell at the beginning of treatment how the patient is going to respond. Yet when they don't and the patient succumbs, some government accountant looks back and complains about "all that money spent in the last month of life," an example of perfect hindsight.

Obviously one key is to improve our prognostic skills while remaining ever vigilant about limiting truly futile care. But how to go about it? How about this: At the time of each hospitalization, the admitting physician makes a guess -- say on a scale of 1 to 100% -- about what he thinks the patient's chances are of living to be discharged from the hospital. Routine elective surgeries would probably garner a rating of 99% (to account for the ultimate unpredictability of everything.) Senile septic ancients might rate a 5% or lower. Don't formally publicize these guesses, but if everyone did it, over time we might very well find our predictive capacities improving. Eventually, physicians might feel empowered to limit aggressive care to those with very low likelihoods of survival. I know this sort of thing may be happening now on an informal basis, but if it were more systematized if might become easier to incorporate into policy.

How about the world of outpatients? Try this: At each patient visit, I generate my 1-100% guess that the patient will be alive after given time, whatever it is. A year; six months; three months; one month; doesn't matter. Formally determining a prognosis for every patient encounter; think about it. It doesn't seem appropriate for well baby care, but for COPD, CHF, CAD patients? Oncologists do this all the time (or at least they should;) why can't the rest of us? What about patients who are healthier, but with risk factors: hypertension; diabetes; sedentary lifestyles?

It's totally unfair -- not to mention illogical -- to bemoan money "wasted in the last year of life" without recognizing that they're talking about a bus that passed our street three stops ago. It's time to be more specific in our conversations about futile care; and a little more honesty and efforts to elevate our prognostic skills to try and approach the level of our diagnostic skills would be a better use of our time and efforts.