Dr. David Tribble

I read with interest a recently posted interview with President Obama on the subject of the peculiar American approach to the end of life, which is more a violent struggle against death. He recounted a situation with his grandmother in which she was suffering from a terminal illness and then broke her hip, raising questions about the propriety of repairing a hip in a terminally ill patient, at the individual and at the societal level. It posed the conflict between the personal result of pain and immobility if the hip were not repaired and the societal cost of hip repair in patients who might not live long enough to justify the intervention, however that might be measured.

I was struck by the assumption that the conflict will always be framed in terms of personal benefit vs. the cost to society. That assumption is simply not accurate. We have well-done studies that show the failure of CPR in end-stage disease; the inability of TPN (total parenteral nutrition, or intravenous feeding) to prolong survival in end-stage cancer; and the futility of 3rd and 4th line chemotherapies in most cancers. Yet we continue to provide these treatments as if failing to provide them somehow short-changes the patient. These therapies do not provide the clear-cut benefit that repairing a broken hip provides, and, in fact, it can be argued that they provide no benefit at all.

I propose, then, that the discussion should start not with the struggle between immediate benefit to the patient and long-term benefit to society, but with absurdity of spending resources that are rapidly diminishing on therapies which we know are ineffective (but which we employ simply because we cannot stand not to). We don’t have to start with challenging therapies that offer a 20% or 30% chance of benefit. We should start with challenging the ones that offer 0% chance of benefit. That, alone, would save hundreds of millions of dollars.

Most hospice physicians I know wouldn’t hesitate for a second to repair the hip, unless the patient were unlikely to survive the surgery. We draw the line at treatments which impose burden without benefit, which is a rational viewpoint for all of medical practice.

Dr. David Tribble is Alive Hospice’s chief medical officer.

Jan Jones

Since Star Trek is here I guess we think everything needs to be done at warp speed! Congress claims to be shooting for a July 31st conclusion to the health care reform process. In many ways I am thirsting for this change as long as it is the right one. I suppose with any change you don’t know what’s right until you’ve actually changed.

For me, the real need is to incorporate decisions about end-of-life care way earlier than what occurs now. Prevention is extremely important and should be properly reimbursed. Listening to patients and families about what is important to them in regards to how they live their lives is critical in supporting decisions regarding health. So, adequate reimbursement for providers to have those kinds of conversations can save many thousands of dollars when health care is actually accessed down the road. 

Most important to me is the issue of how one chooses to live at the end of life when medical science has exhausted known cures. This is a family discussion, not a medical decision, yet our current health care system does not recognize this as valuable enough to reimburse adequately for this. How short-sighted that has been. I am encouraged by the interest shown by our legislators in addressing this thorny issue.

Did you know that 1/3 of all Medicare expenditures occur during the last year of life* with 1/3 of those exenditures in the last 30 days**? What an opportunity for hospice and palliative care to be part of the solution since we actually save many dollars by avoiding treatments that are very costly and not helpful.*** (That is not to say that we don’t provide costly treatments. We certainly do, but only those that actually address the underlying symptoms.) Recent research has also shown that individuals who access hospice services on average live 30 days longer than those who do not.****

So my hope is that, warp speed or not, health care reform becomes more healthy by actually addressing end of life care in a way that is meaningful to all of us and in turn saves our system much needed dollars.

What do you think?

Jan Jones is president and CEO of Alive Hospice.