Will to live

A patient asked me today what the difference was between dying and living the final month of her life in the hospital. It was a good question and got me thinking about a concept I have discussed with some of Boston's best palliative care experts during my residency and fellowship. The concept is one of prolonging death vs. ending life- and this is the single most important concept in the US healthcare system today, and one of the least discussed. Let me explain:


First, the facts:


1) Medical care at the end of life consumes 10-12% of the total health care budget and 27% of the Medicare budget.

2) 7-30% of total Medicare budget is spent in the last year of life

The Dartmouth Atlas Project published a few years ago studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. This study demonstrateed that even within this limited patient population, Medicare could have realized substantial savings—$40 billion or nearly one-third of what it spent for their care over the four years—if all U.S. hospitals practiced at the "high-quality/low-cost" standard. The study painted a picture of the health care system in disarray over the treatment of chronic illness.

Basically, there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:

--Both doctors and patients generally believe that more services—that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc.—produces better outcomes.

--Based on this assumption, the supply of resources—not the incidence of illness—drives utilization of the services.

In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.

SO what does this ALL mean in english? Patents without living wills have thousands of dollars of healthcare expenditure in their final days, often regardless of their prior preferences as family members dictate their care, and little of this healthcare lends itself to a better quality of life, better outcomes,. So think about this: Would you rather, in your final days, with a debilitating condition, let nature takes its course, or have medicine prolong your death? If the answer is the former, time to sign a living will. No matter what your loved ones say, you'd be suprised how difficult it is, in the final hours of a family member's life on earth, to own responsibility for pulling back treatments, tubes, machines... and the living will takes all of the guilt and puts it squarely where it belongs: on the shoulders of the patient, years before they lost themselves to the inevitable.