Discussing end-of-life care in the ICU and saving Medicare money

I think by now there is not a person in the US who cannot quote at least approximately how much we spend annually on healthcare. Fewer people appreciate that nearly 1/3 of this $2.2 trillion bill is eaten by hospitalizations, amounting to about $680 billion. Although the data in the diagram below represent a single year, the overall distribution of expenses is remarkably constant over time.

Discussing end of life care in the ICU and saving Medicare money

Of this staggering amount of money, no less staggering is the ICU expenditure, quantified at nearly $60 billion in 2000.

The role of the ICU is to support a patient through his/her critical illness. The reason ICUs exist is that these patients require more intense human and technological interventions, and this geographic segregation allows for more efficiently concentrated care. The philosophy behind putting a patients in the ICU is that of a therapeutic trial. In other words, no one knows for sure a priori whether the ICU intervention will make any difference in the individual patient’s outcome. What we have to go by is evidence from studies of similar patients that tells us what on average the expected outcome may be.

Until about a decade ago we never had the luxury of inquiring about what an ICU survivor might be doing a year later: we were fixated only on getting the patient through the acute illness. In fact, about 10 years ago, when I had the chance to ask a very well known and respected academic intensivist whether he cared about what happened to the patient once the ICU doors closed behind him, he, like so many of his peers, gave a resounding “no”.

Well, we have learned a lot over the last two decades about how to improve ICU outcomes — more patients are surviving to leave the ICU. So now we have started to be concerned about their longer-term outcomes. After all, surviving an ordeal today just to die or, even worse, wish you were dead, tomorrow is not the kind of a victory anyone would want to claim. Unfortunately, what we are learning is that their long-term outcomes are not particularly encouraging. More than half of those patients who survive a prolonged critical illness die within the subsequent year.

Even more discouraging is that fewer than 10% are actually at home living independently. So, when starting a therapeutic trial of an ICU, both the clinician and the family of the patient need to have a clear end in mind, so as to minimize pain and suffering for both, the patient and the family. And a byproduct of this conscious minimization of suffering through inappropriate care is potential avoidance of economic ruin.

What triggered this rumination for me is the paper published in this week’s New England Journal of Medicine looking at the clinical course and outcomes of nursing home residents with advanced dementia.

In this prospective study following 323 patients, more than one-half were dead by 18 months. This is not in and of itself surprising. What should, however, shock an uninitiated reader is that 4 out of 10 of these unfortunate patients undergo at least one burdensome intervention, including a hospitalization or an ED visit, in the last 3 months of life. Although as a former clinician I have no trouble believing this number, as a member of the human species I am absolutely appalled! Is there really ever a point to such torment knowing that any potential postponement of death is at best temporary and at worst painful for the patient?

Another interesting point in this study is that what reduced the likelihood of this infliction of pain was a clear understanding by the patients’ loved ones of their dismal prognosis. So, although some of the less informed yet loud and disingenuous voices tout them as government-sponsored death panels, the reality is that end-of-life discussions are not intended to limit necessary care. Rather, their intent is to create an honest and transparent dialogue between the clinicians and the patient and his/her family, thus empowering them to make the right choices according to their values. Perhaps the fear-mongers in their torrent of feverish activity have been too busy to notice that the age of paternalistic medicine is over. In the 21st century patient empowerment is the mantra. End of life discussions are just that, empowering.

If I were a politician driving a message, I would stop here. I would not connect this message of empowerment to dollars. But I am an outcomes researcher, so I must. There are examples in corporate America who say that if you do the right thing for the customer, the money will follow. To me this is simply an extension of the golden rule. Call it karma, call it what you will, but doing what is right is often contagious and causes a domino effect.

And yes, in the case of spending the necessary time with the patient and the family to discuss the best course of action, the desired byproduct may be to help curb the waste of Medicare dollars on useless interventions, thus ensuring not only the best for the patient, but also the program’s sustainability.

Marya Zilberberg is founder and CEO of EviMed Research Group and blogs at Healthcare, etc.

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  • Finn

    I agree completely on the issue of prognosis and end-of-life planning. However, 3 things jump out at me from the pie chart:
    1. What is “Other Spending”? Since this constitutes 1/4 of the total expenditures, it seems too important to be unexplained.
    2. Prescription drug costs, at 1/3 the cost of hospitalizations, seem outrageously high.
    3. At only 7%, program administration seems to be a bargain. How many insurance companies can match that figure?

  • christophil M.D.

    You argue prognosis and end-of life-planning are linked and need to be discussed openly and honestly. Poor prognosis implies a level of futility and wasteful spending. Empower patients with knowledge of their prognosis (what makes you think that prognosis is not discussed?) and they will make the “right decision” and as a byproduct we will curb “wasteful spending”. But, are you willing to extend this argument from the demented elderly ICU patient to all prognosis challenged patients- e.g. the alcoholic or the cancer patient or the HIV infected. Why cherry-pick-on the elderly?

    Furthermore, you are “shocked” that 40% of nursing home residents with advanced dementia In cited prospective study undergo at least one “burdensome” intervention, including a hospitalization or an ED visit, in the last 3 months of life. I am sure that my caring colleagues in the ED and hospital don’t see their interventions as “burdensome”. Why do you?

    Finally, paternalistic medicine is dead, patients are free, free to fight for life despite the prognosis and cost. Would you have it any other way?

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    My mother in law had dementia for years, she fell and died shortly after. Had she not fallen, had she been cared for as well as a 20 yr old who fell, she would have continued to live. My aunt is 102 in a nursing home for years now due to lack of vision. At 85 she was told not to bother with gall bladder surgery, since she would be dead soon. She got mad and the surgery was done. How dare you let statistics or money play God? YOU could be dead in a car accident today. End of life care should be discussed as common education in schools. Be a doctor. If you are not a doctor to heal the sick, please find another job. Try Wall Street if you are into stats and dollar costs. I was in an ICU for FIVE days, over $60,000 NOBODY ever asked how I was later. And no tests, no doctor, found anything wrong with me. I had MS and had to explain to every nurse, aide, and a couple PTs and DOCTORS what MS was. I am 52. Cost effective? Start with education and better hospitals, not senior citizens and the chronically ill. Oh, I seem to be fine now. Thanks for asking.

  • Anne Marie

    A piece of that pie should reflect the money wasted on fraud. Medicare fraud alone costs us $60 billion a year according to a 60 minutes segment that aired tonight.

  • steve

    anne marie

    But if you believe that story and the rooney segment that aires along with it, then you are likely not in medicine. the fact is a lot of what is considered ‘fraud’ is only so because of paperwork which is not filled out to the medicare specifications. it does not reflect work that was not done. if you took a look at tis from the opposite side, which I never see done, you would be astounded at the amount of things which get done by clinical people which never get reimbursed by medicare because a T was not crossed, or an I not dotted.

  • http://hightechsurgeon.blogspot.com Joseph F. Sucher, MD FACS

    This “rumination”, like so many others, appears to create controversy than it does to clear up any points. Unfortunately, what I read here is a poorly framed story that mixes and mashes up a plausible discussion with errant factoids that are based on partial truths. Ultimately, the author’s point is lost and controversy with mudslinging ensues.

    I will make the assumption that the author simply desires to make a point that we as a health care community can do better for our patients and that discussing end-of-life issues is an important part of good medical care. However, past this ideal, little of her argument helps the reader understand the truths about ICU patients because she mixes fact with partial fact.

    The author begins with the enormous cost of ICU care. This very general broad stroke is painted and creates the initial problem. There are many differences between “ICUs” (Surgical, Medical, Cardiac, Cardiovascular, Neurosurgical, Transplant), and their respective patient populations. This should have been more focused because the author then grabs statistics (below) from a study that describes nursing home residents (a narrow population). The author’s argument is now poorly framed and setup for controversy (mixing broad fact with narrow factoid).

    “More than half of those patients who survive a prolonged critical illness die within the subsequent year.” and “Even more discouraging is that fewer than 10% are actually at home living independently.”

    The reader is left to believe that somehow, ALL ICU patients have a 10% chance of living independently and have less than a 50% 1 year survival. Then the author delves into the end-of-life debate with this money argument. That is a mix that only serves to stir up the pot. I would argue that you can sell the end-of-life discussion very well if you leave money out of the picture. People understand good-intentions and caring doctors. But throw money into it and you have completely given up those ideals. What ensues next is the mudslinging and misdirection from the readership.

    For example – Diane J Staniford: “Be a doctor. If you are not a doctor to heal the sick, please find another job. Try Wall Street if you are into stats and dollar costs.” and Finn “What is “Other Spending”?”.

    These statements from the readers really mean the topic of end-of-life discussion is completely lost. The fact is, this is a really important topic. End-of-life discussions are meant to be inclusive of the patient and family belief systems with the physician playing a role of information expert, thus delivering and explaining information in such a way as to help that patient or family make the best decision(s) possible. Despite what the author says, long-term outcomes of ICU patients are, in general, very encouraging in a broad sense. However, there are indeed many patients with truly critical illness that we cannot predict with certainty what their individual chance of survival will be acutely, not to mention long-term. We can only utilize our understanding of statistical probabilities to help best inform and serve our patients and their families.

    So, my take. End-of-life discussions are important. Statistics, when used intelligently and honestly are important. Put the two together to best help your patients, with everyone understanding that there are limitations to what we know and what we can do.

    note to Diane J Staniford: Medicine is a profession that must rely heavily on statistical probabilities to make the most informed decisions possible. This fact does not impair personalized medicine, but is in fact is the best tool we have available in a world of made up of probabilities and a future that nobody can predict. Therefore, your inflammatory comment about leaving medicine and going to Wall Street is not valid and deserves retraction.

    JFS

  • Anne Marie

    Steve,

    The fraud reported in the 60 minutes segment I was referring to was about bogus companies that set up closed door shops in minimalls and sold non-existant medical equipment to phantom people, then billed the government. Not what you stated in your post.