Death by Rationing? Not Here

So much of the debate over controlling health care costs at the end of life is of the either-or variety: give patients access to all available treatments or condemn them to death by rationing. As Dr. Laura Carstensen, director of the Center on Longevity at Stanford University, puts it in an excellent front page article in The New York Times, “Either we have to throw everything we’ve got at keeping people alive or leave them on the sidewalk to die.”

But the article, written by Jane Gross, who created the Times’s New Old Age blog, gives lie to that simplistic way of thinking. “Sisters Face Death With Dignity and Reverence,” looks a congregation of nuns in a Rochester, N.Y., who live out their final days in a facility that provides excellent palliative and hospice care, along with social and intellectual engagement up until the very end. It’s not that the nuns are denied aggressive life-extending treatments; but few choose them.

Sister Dorothy Quinn, for example, 87 years old and dying of heart disease, decided not to take most of the 23 medications that had been prescribed for her. She also declined to have a mammogram to determine if a lump in her remaining breast was cancerous, “understanding that she would not survive treatment,” Gross wrote.

This sort of decision-making is possible because of an environment where doctors talk to patients frankly and openly about their conditions, the likely benefit from various treatment options, and death.

The experience is in stark contrast to that of most patients dying in hospitals, which often leads to the use of expensive and futile treatments at the end of life, as described in several posts here.

One post discussed the dramatic increase in the use of life-extending treatments for people in their 80s and 90s, including kidney transplants and dialysis.

In another post, Harvard geriatrician Muriel Gillick described a man in his late 70s who had had a massive stroke and was “being kept alive in the ICU with a variety of high-tech interventions.” His wife agreed to the treatments because the doctor hadn’t explained that even if he survived the ICU, rehabilitation would be grueling and he would either die or be extremely debilitated.

“Once she understood both what treatment would entail and how unlikely meaningful recovery was, she had no further hesitation: the right course of action for her husband was to focus exclusively on his comfort,” Gillick wrote.

In the Times article, Dr. Robert McCann, the geriatrician who treats the nuns, says that “they have better deaths than any I’ve ever seen.”

He goes on to say, “It is much easier to guide people to better choices here than in a hospital, and you don’t get a lot of pushback when you suggest that more treatment is not better treatment.” In an audio slideshow, McCann says that he uses one-third the amount of narcotics for the nuns than for his patients dying in other facilities because the nuns have less need for the drugs.

The article clearly touched a nerve. It was the most frequently e-mailed New York Times article on July 9, and received dozens of comments, most full of praise for the end of life care described.

Could that kind of care take hold outside the convent, in the rest of the country? Gross is hopeful that it might. The nuns there “animate many factors that studies say contribute to successful aging and a gentle death – none of which require this special setting,” she wrote. “These include a large social network, intellectual stimulation, continued engagement in life and spiritual beliefs, as well as health care guided by the less-is-more principles of palliative and hospice care – trends that are moving from the fringes to the mainstream.”

To give that trend a push would probably require a change in Medicare proposed by Gillick in another previous post here. As it stands now, she wrote, Medicare reimbursement favors “burdensome, expensive, treatments at the end of life.” It also provides excellent hospice care, but only if patients make a “diabolical choice” – agreeing to forgo some palliative treatments that can ease their symptoms, such as oral chemotherapy.

Gillick said that a better and potentially money-saving option would be to provide hospice care along with some hospital care, but excluding the most expensive kinds of interventions, such as major surgery and ICU care.

It’s not either-or, everything or rationing. And, based on the comments on the Times article, it’s an option that many people would gladly choose for their last days.

Susan Gilbert is the associate editor of the Health Care Cost Monitor and the staff writer of The Hastings Center.

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