A quarter of Medicare dollars are spent on patients who are in the final year of their lives, according to the Center for Medicare & Medicaid Services. In a Tuesday afternoon break-out session during Hospital of Tomorrow titled "Fixing End-of-Life Care," experts discussed how patients could live well during their final days or months, and how health care professionals could intervene in ways outside the hospital. They concluded that people prefer a life that has greater quality over one that is longer.
Speakers included Diane Meier, director for the Center to advance Palliative Care at the Icahn School of Medicine for Mount Sinai; Scott Shreve, D.O. for the U.S. Department of Veterans Affairs and Lebanon VA Medical Center; and Daniel Hoefer, chief medical officer for SharpHospiceCare. Anne McGrath, managing editor for U.S. News, moderated the session. Here are the highlights:
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The United States has the lowest support of social care than any other nation on earth, Meier said. In Denmark, for example, spending on social programs is 2.5 to 1. In the United States it is 0.8 to 1. Part of the problem with end-of-life care is that we do not have social support, she added.
Depression is the greatest independent predictor of mortality, Meier said. If you are depressed you will die significantly sooner, regardless of whether you have heart disease, dementia, emphysema, etc. "It is a poor prognosis," she said.
More veterans die in hospice beds than anywhere else, according to Shreve.
"The VA, with its electronic medical record can go out proactively ... and start offering palliative care," Shreve said. Palliative care is short-term, end-of-life care that serves to relieve pain and put patients at ease psychologically.
The problem with giving a hip replacement to a patient who is very elderly is that they are at high risk of developing hospital-induced delirium, Hoefer said.
Before you need palliative services, the American health care system needs to have discussions with the individual over whether that person wants those services in the fist place, Hoefer said. "Our health care system is still based on a reactive model of reimbursement," he said.
There should not be hospital readmissions for patients with chronic care, Hoefer said. The problem with the current reimbursement model, he said, is that health care organizations do not get reimbursed if people do not keep showing up.
Most health care practitioners were not taught how to have a conversation about end-of-life care that is based on what is most important to the family, Meier said. They try to avoid talking about death rather than talking about the quality of life during end-of-life care. This model, though it might make sense, isn't a part of the United States' health care model because most of health care is still based on fee-for-service care, she said. Some members of the audience said they often found many patients would rather extend their lives, however, even if they might have an extremely low chance of survival.
Experts tried to shift the conversation about end-of-life care toward how to improve people's quality of life, to make patients comfortable during their final days or months in a way in which they no longer live in fear. Patients prefer to talk about what their goals are in their lives, such as reaching the birth of a grandchild or living long enough to see a daughter's wedding, experts agreed. They may choose to focus on managing their pain rather than deciding to undergo a particular procedure in which death is highly probable, Hoefer said.
Corrected on : Corrected, 11/15/13: In an earlier version of this article, a quote was incorrectly attributed to Dr. Diane Meier of Mount Sinai Hospital. The quote has been removed.