Editorial: End-of-life care with compassion, cost savings

Paul Dunham died at his daughter’s home on Monday, just as he had chosen. Like most people, Dunham didn’t want to grow old in unfamiliar surroundings. Thanks to the increased flexibility of government-subsidized care, he was able to stay at his Hayden mobile home, with assistance from a visiting caregiver.

Not only did this fulfill his wishes, it saved taxpayer dollars. Instead of government paying for more expensive nursing home care, it granted a Medicaid waiver so that Dunham, who had a debilitating neuromuscular disorder, and his ailing wife could get 25 hours a week of help at home. The monthly cost was $1,500, as opposed to the $5,000 to $7,000 it would take to cover a nursing home.

It’s not often that compassion and cost-cutting go hand in hand, so it’s unsurprising that this has become a popular trend. Nearly 30 years ago, four of every five dollars for government-paid long-term care in Washington state went to nursing facilities. Now, about two-thirds of those dollars go to people who remain in their homes.

Still, there is room for improvement. And when you consider that one-third of all U.S. health care spending is directed toward the last year of life, it’s clear that there are huge opportunities for saving money. Dr. Jonathan Bergman of UCLA recently conducted a study of the issue and told Reuters, “We might be able to do a better job with end-of-life care and cut costs not by rationing care but by making it more rational and treating each patient based on their original goals.”

Please note that he is not talking about rationing care, which has become a political hot potato, but about respecting the wishes of patients. As long as patients make their desires known and health care providers abide by them, this aspect of health care spending can be reined in. That’s why our system should encourage advanced-care directives by paying doctors who take the time to assist families with thoughtful discussions about end-of-life care. Currently, it only rewards testing and treatment.

Hospice is an encouraging avenue, but Bergman found that one-quarter of hospice patients are there for less than a week. To reap the full benefits, patients need to enroll sooner. Such care typically lasts a maximum of six months and enrollees opt for less intensive care.

Though most cancer patients prefer to spend their last days at home, 29 percent died at hospitals from 2003 to 2007, according to the Dartmouth Health Atlas. Regional variations are startling and suggest that a lot of care is wasted. In Spokane, 25 percent of cancer patients died at hospitals. In Los Angeles, it was 40.5 percent. In Mason City, Iowa, it was 7 percent.

Similarly, inpatient care in the last six months of life varies widely throughout the country. For Medicare patients, Dartmouth found that it was 6.7 days in Spokane and 14.7 days in Los Angeles. Life expectancy was not improved with more intensive care.

We’re encouraged by a trend in end-of-life care that fosters independence, compassion and cost savings. But if we hope to get health care spending under control, we must do better.