Few Americans make end-of-life wishes known
FORT LAUDERDALE (AP) – Lillian Landry always said she wasn’t afraid to die. So when death came last week, the 99-year-old was lying peacefully in a hospice with no needles or tubes. Her final days saw her closest friend at her side and included occasional shots of her favorite whiskey, Canadian Mist.
Landry is an exception. Unlike most Americans, she made her end-of-life decisions years ago: no heroic measures to save her and even instructions on the bar where mourners should gather.
The health overhaul bill that narrowly passed the House on Saturday includes a provision to nudge more people to confront such choices: It would pay for end-of-life counseling for Medicare patients.
Supporters say counseling would give patients more control and free families from tortuous decisions. Critics have warned it could lead to government “death panels.” What few on either side note is that counseling could lead more people to choose less intensive care when they’re dying, and ultimately trim government-funded health bills.
Hospice care has grown from about 25,000 patients in 1982, when Congress approved coverage under Medicare, to 1.45 million people in 2008. It’s for patients who have a prognosis of no more than six months – and it ranges from in-home care to stand-alone centers to special wings in hospitals. It does nothing to artificially lengthen or shorten life, focusing mostly on a patient’s comfort.
People on Medicare account for the vast majority of U.S. deaths, and care in the last year of life accounts for roughly a quarter of Medicare’s budget. So increased use of hospice could mean sizable savings for the government, particularly if patients enter it sooner.
A 2007 study published in the journal Social Science and Medicine found that among Medicare patient deaths, those who used hospice saved taxpayers an average $2,309 over their last year. In some cases, the savings were as much as $7,000, depending on the illness and length of hospice stay.
Still, only about 39 percent of Americans who died last year were in hospice. The average patient spent a little more than two months under that care; about a third moved to hospice only in the last week of life.
“It’s significantly underutilized. People are referred very late,” said Dr. Richard Payne, a Duke University professor who heads the school’s Institute on Care at the End of Life.
“Our culture just doesn’t tolerate talking about death and dying. And the minute you even start talking about having conversations with a doctor, it’s immediately pejoratively labeled as ‘You’re trying to kill me.'”
That perception is precisely what got affixed to the counseling measure in the House bill. Even though the legislation specifies counseling wouldn’t force patients to limit efforts to keep them alive, and even with the support of the American Medical Association, AARP and others, suspicion has lingered, encouraged by conservative voices including Sarah Palin.
Dr. Jim Small, a Denver pathologist who belongs to the Christian Medical and Dental Associations, said he feared the provision would be twisted into something more intrusive if bureaucrats lay out the details.
“It’s incredible micromanagement,” Small said. “End-of-life discussions are part of normal, good patient care, but there’s no reason for it to be in the bill.”