15 years ago, Drs. Zeke and Linda Emanuel wrote an article in the New England Journal of Medicine titled, "The Economics of Dying - The Illusion of Cost Savings at the End of Life." They present the potential cost savings if all persons who died in a particular year executed an advance directive, chose hospice, and refused in-hospital treatment at the end of life. Savings? 3% of health care spending, max. Max. Their conclusion:
The unlikeliness of substantial savings in health care costs does not mean, however, that there are no good reasons to use advance directives, fund hospice care, and employ less aggressive life-sustaining treatments for dying patients. Respecting patients' wishes, reducing pain and suffering, and providing compassionate and dignified care at the end of life have overwhelming merit. But the hope of cutting the amount of money spent on life-sustaining interventions for the dying in order to reduce overall health care costs is probably vain. Our alternatives for achieving substantial savings seem limited to major changes in the financing and delivery of health care, difficult choices in the allocation of services, or both. Whatever we choose, we must stop deluding ourselves that advance directives and less aggressive care at the end of life will solve the financial problems of our health care system.I am reminded of this article for two reasons. First, the vituperative reaction to proposed health care legislation that would compensate physicians for advance care planning. The argument against the legislation runs something like this, "Advance care planning is a way of saving money by killing patients. Bureaucrats in Washington want to decide who is worth saving and who should die. Don't let this happen to your grandma!" This is all utter nonsense, of course, but cleverly done. The argument plays into a suspicion that the real motivation behind hospice and palliative care is limiting or denying care and reducing end of life costs. In the years since Drs. Emanuel and Emanuel published their paper, researchers have established the cost savings of inpatient palliative care, primarily through reduced lengths of stay. This research has been misconstrued to play into the fear that the real motivation behind hospice and palliative care is to save money. Well...that's why I trained in palliative medicine. To save money. Right? Wrong. Here is an excerpt from a grant I wrote recently about my commitment to the field of palliative medicine:
During medical school my father was diagnosed with brain cancer and died. I cannot, nor would I wish to, separate the indelible impact of my father’s dying from my lasting interest in palliative care. Anecdotally, I have found that many in palliative care have been wounded in a way that shaped their choice of profession. Over the years, I have also come to appreciate the ways in which palliative care privileges me to focus on aspects of care that brought me to medicine in the first place: attention to the whole person, helping others, and constant discovery. On a daily basis, I feel honored and privileged to care for these patients and their families.Did you spot the bit about cost savings? Nope. Admittedly, cost savings are a nice bonus. Hospitals have "bought in" to inpatient palliative care because they believe in the reduced length of stay data. The cost savings argument is responsible for the boom in hospital-based palliative care programs across the country, in contrast to geriatrics, which has yet to establish itself outside of academic centers. But cost savings have nothing to do with the core reasons why we believe in what we do.
The Emanuels' paper came up again in the context of today's palliative care journal club at UCSF, a RCT of a nurse-drive palliative care intervention published in JAMA. (Pallimed has an interesting discussion of the article). Advanced practice nurses called patients newly diagnosed with advanced cancer and coached them in goal-directed problem solving around social, communication, and symptom issues. The remarkably comprehensive handbook nurses used can be found here. Compared to usual care, the intervention arm had better scores for quality of life and mood, but no difference was found in hospital, ICU, or ED use. Costs were not measured directly, but you get the sense that this is not a cost savings intervention. You also get the sense that it wasn't terribly expensive.
Should we fund interventions like this "merely" because they improve quality of life for patients living with life-threatening illness? How about "yes." We should fund these palliative care interventions not because they will save money, much less rescue our costly health care system, but because they are fundamentally the right thing to do. The origins of hospice and palliative medicine are rooted in a desire to improve quality of life, in cherishing the value of life, "live everyday as best as you can," -- not in limiting or denying care to save money. We need to be clear about how we promote ourselves to others, before we are labled as standing for something we do not.
Time to fight for our image.