Clinical Geriatrics

Healthcare coverage has historically focused on providing acute life-sustaining services, but there has been growing attention paid to improving end-of-life care. This attention has been increasing as of late in healthcare reform, with other recommended changes being proposed. Of course, end-of-life care is critical from a cost perspective—both emotional and financial.

This issue is especially keen at this time given the concern by many over healthcare costs, specifically concerns with ineffective treatment at the end of life. Studies have shown that approximately one-third of Medicare expenditures in the last year of a person’s life are spent in the last month.1 A high proportion of those costs come from life-sustaining procedures and care such as ventilator use and resuscitation.2 For these dollars, little results in improvements in the quality and length of life for seniors. As studies on regional variation from Dartmouth have demonstrated, there is not always a correlation between cost and quality; in fact, sometimes the inverse is true.3

Despite the cost both to society and the government, from an individual standpoint a 2006 survey showed that more than 33% of all Americans would want their physicians to do everything possible to extend their lives, regardless of price.4 This is a significant increase from 1990, when 20% believed this.4 This is probably due in part to reduction in out-of-pocket expenditures and increases in technological advances, which have resulted in increased opportunities at less of an individual financial cost.

There are opportunities for improvements in end-of-life care. Advanced cancer patients who have end-of-life discussions with their doctors appear to have better quality of life in their final days and pay significantly less for that care, according to a new study published in the Archives of Internal Medicine.5 This conclusion is supported by a study that supported the same direction as the literature, in that there is real potential for end-of-life services to reduce expenditures associated with hospitalizations, while at the same time accommodating the expressed preferences of patients.6

Healthcare costs for patients who had end-of-life conversations with their doctors were estimated to be an average of 36% lower in the last week of life than for patients who did not talk with their doctors. There was no difference in survival or in psychological distress between the two groups. However, patients who did not have end-of-life conversations with their doctors experienced more physical distress in the final week of life, as reported by nurses and caregivers.5

So, both the emotional and financial costs can be improved through a greater focus on end-of-life care. There is a belief that promoting policies that increase communication between doctors and patients could lead to better quality of life and lower costs at the end of life.

Advance Directives

Governmental attention on advance directives started in 1990 with the Patient Self-Determination Act (PSDA). PSDA is a federal law passed by Congress that requires Medicare-reimbursed facilities to inform all adult patients about their rights to accept or refuse medical or surgical treatment and the right to execute an “advance directive.” PSDA defines an advance directive as a written instruction such as a living will and durable power of attorney for healthcare recognized under state law relating to the provision of healthcare when the individual is incapacitated.

The recent healthcare reform legislation in the form of the house bill titled America’s Affordable Health Choices Act (HR 3200) makes attempts to promote advance directives.