Dying In America: Care Should Be Kinder
A new report calls for overhauling the way we deliver end-of-life care
Editor's note: This article is part of a year-long project about aging well, planning for the changes aging brings and shaping how society thinks about aging.
Last week’s release of the Dying in America Report adds to the discussion those of us in the field have been having for years. Its 507 pages clearly demonstrate that our country's system of delivering care to the elderly is badly broken.
The Institute of Medicine’s (IOM) report is especially timely as the number of those suffering from “some combination of frailty, physical and cognitive disabilities, chronic illness and functional limitations,” grows.
We need more care that puts these patients — no matter their wealth or cultural background — at the center of care.
Another key point the report makes is that we need to understand how care needs have changed and why Medicare should support long-term care.
To paraphrase Hamlet, the health care system is out of joint. It simply has not kept up with the change in disease patterns. We have built the equivalent of a medical Maginot Line. Just as the French built fortifications to refight World War I only to have them totally circumvented by armored columns, we remain geared up to fight against acute disease in an era dominated by chronic illness.
The Dying In America report's finding that we spend large amounts on ineffective (and often dangerous) care at the end of life is but one symptom of this much larger problem.
Time to Take Stock
Let’s take stock of where we are and how that matches what we need.
An acute care model has a patient coming to see a clinician to get a specific treatment for a well defined condition. In a chronic disease world, visits are not made for precise treatments. Rather, patients’ clinical courses need to be followed. Successful disease management is defined as preventing catastrophes (i.e., acute episodes). Direct contact with clinicians is less useful than systematically tracking a patient’s status and intervening at the first signs of change.
Such a program requires a different payment system. The old fee-for-service model, which rewards doctors for seeing patients and doing things, must be replaced with one that rewards active monitoring (using a variety of devices) and intervening early.
This monitoring should typically not require in-person visits. Under such a system, doctors and patients would set goals and expected courses for a given disease. Patients would provide regular data to assess their clinical course. No actions need be taken as long as the data suggest the patient is on the expected trajectory.
But if there are signs of deviation (after doublechecking the veracity of the data and establishing that the patient was adhering to the prescribed treatment regimen), then a comprehensive assessment is necessary.
One immediate result of this new strategy is the end of the return appointment. This custom accounts for almost two-thirds of doctor visits, but it is very wasteful. Expecting a physician to ascertain the next time a patient should be re-examined is an act of medical hubris. It is not a coincidence that this custom generates visits and visits generate fees.
Imagine what could happen if we re-programmed all those costs into a prospective monitoring and intervention system (and simultaneously changed the payment system to one rewarding catastrophe prevention).
This same line of reasoning was used in the report's examination of end-of-life care. Clinicians trained to employ technology and believing in its usefulness (and rewarded well for employing it) may be overenthusiastic in recommending it, especially since much of it takes a heavy toll on comfort and function.
More discussions with patients about expected courses and risks and benefits might lead to other decisions about forgoing some of these intrusive treatments in favor of other outcomes.
Here is an area when we actually can do well by doing good. We can save money and improve quality of life.
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