Thursday, August 26, 2010

Caveats to “letting go”

A recent NYTimes article comes at the heels of Dr. Gawande's compelling essay on end of life care. The matter at hand is that legislators are realizing the economic value of palliative care options for terminally ill patients. Recently, Gov. David A. Paterson signed into law a bill — the New York Palliative Care Information Act — requiring physicians who treat patients with a terminal illness to have frank discussions about prognosis and options for end-of-life care, including aggressive pain management and hospice care as well as the possibilities for further life-sustaining treatment. A similar law in California seeks to overcome physician resistance to talking openly with terminally ill patients about end of life care options. As part of the original federal healthcare overhaul, a similar provision would have reimbursed doctors for the time it takes to have such conversations – which however did not make through it given the traction gained by "death panels". Overall, even commercial insurers have financial incentive to steer patients with a poor prognosis away from costly health care services.

The point is that there is a cost advantage, in addition to the better quality of life argument. Several studies reveal that palliative care and hospice services can reduce costs of can-do-aggressive medicine anywhere from 20 to 35 %. Given that end-of-life costs make up a quarter of the Medicare budget, steering patients away from the ICU makes for good economics right? If that is the case then shouldn't all states follow suit? There are caveats however - that are well brought to our attention in this write up, on the Disease Care Management Blog.

Doctors cannot predict the end of life: "When confronted with a critically ill cancer patient, popular culture would have you think the physicians can predict the likelihood of not making it out of the ICU alive and can therefore treat accordingly. The problem is that the prediction is far from perfect with an ROC, according to this study, of about 0.8 (where 1 is perfect). In other words, there are enough false positives to give physicians pause before recommending pulling the plug." Further, "for non-cancer patients, the prognostic tools are even worse".

Research on hospice is on shaky ground: "given our national manic compulsion for "evidence-based" science to guide treatment decisions, that the research supporting the benefits of hospice is decidedly shaky. Dr. Gawande only quoted some studies that happened to support his point of view"

Having said that, what could change is a physician's perspective on palliative care – not as an option after all else fails.


  1. The study you cite is only a study of if the people survive the ICU and live to hospital discharge. It says nothing about the patients' quality of life after surviving the ICU, or how long they survive after discharge.

    The question really should be how do we provide the best quality of care to patients at the end of life? I think the take away point of Gawande's article is that we should be encouraging patients to be making decisions about their end of life care, rather than avoiding making decisions. Certainly hospice needs more evidence, but so do all of the medical procedures we subject dying patients to.

  2. Heather - Thanks for this. You do bring up a good point - which would require several years of a longitudinal research design to follow-up with patients. Having said that - it does raise questions about the appropriate use of ICU resources.

    I also agree with your second point - patients should be involved in such decision making.

    I suggest having a look at the DCMB blog here:

  3. All fair points. Grappling with cost-effectiveness at the end of life is extremely challenging. On one hand ICU care is very expensive and there is new data suggesting that for many patients it not only does not extend life, but as Heather points out may adversely effect quality of life. At the same time, families and healthcare professionals are unaccustomed to the idea of allowing death and our system is primed to spare no expense or resource.

    This is precisely why it is important for everyone to communicate their wishes for end of life early, and it is important that physicians begin these conversations with patients when they are healthy.

  4. Hi Heather:

    You bring up a good point. I recalled reading a study years ago showing that ICU nurses were unable to predict patient perceptions of quality of life after discharge. Patients rated living as a good thing, while the nurses estimated that life was lousy. If anyone is familiar with some data on this, please share.

    Jaan aka the DMCB

  5. However, many family members that care for their loved one on hospice services view their efforts as one gift to their loved one. Thanks for sharing.