Human nature prevents any cost savings at the end of the life

We are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning.  Living wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. Patient “L.J.” is my first example.

I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.  Three years ago he went into a severe depression after losing his second wife, to dementia.  His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs.  He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.

In recent months he has refused to be transported to an infusion center for his transfusions.  Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to.   His nurse has become exceptionally attached to him.  As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.

Three months ago she suggested a palliative care consult.  I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs?  The children had demanded the palliative care consult so one was called.

The local hospice program has a new palliative care program. They bill Medicare Part B for their services.  The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services.

Three months later the same nurse contacted the family and said the patient needs hospice care. I asked “why”?  She told me her mother had died of cancer and hospice had been very helpful. I have no objections to working with hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point.  When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.

It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care.   The taxpayers’ foot the bill as the system fails from expenses it cannot meet.

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

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  • Marianne Evans

    I am a hospice physician. I am glad your patient is having no symptoms, however, at some point he certainly will have dyspepsia from his severe anemia, and perhaps high output heart failure or an MI as well. At that point, the nursing home can call the hospice nurse instead of 911 and he can receive oxygen, morphine, and any other medications for his symptoms at end of life. In my long experience of nursing homes, if he were not in hospice, as soon as he begins to show end of life symptoms he will be transported to the ER via 911, have labs and X-Rays, a CT of his head if he has “altered mental status”, possibly transfusions if he is not with it enough to refuse, and so on, all of which will cost the same as about 6 months of Hospice. Also, “just” social work and chaplain visits are not “nothing” to this grieving man whose depression does not respond to pills because we have no pills for existential distress and despair That’s where the spiritual support comes in, even if he is an atheist like me, we all have existential questions and fears. Hospice is highly cost effective for cancer patients and probably cost neutral but certainly more apprproate for other patients with end-stage disease.

    • Guest

      “That’s where the spiritual support comes in, even if he is an atheist like me, we all have existential questions and fears.”

      But is that the sort of thing we should be spending our scarce and rapidly-depleting Medicare dollars on, or should the government focus its medical spending on medical care and encourage people to make their own provisions for “spiritual care”?

      If atheists find themselves suffering existential angst and needing “spiritual care” when they’re ill, then perhaps atheists should form the non-believer equivalent of churches/synagogues/mosques and minister to their own, rather than asking the government to provide and fund it out of scarce healthcare dollars.

      • Steven Reznick

        The caregivers in Hospice even in the Medicare funded entities of today are angels of mercy . They are kind , caring , dedicated human beings . If camraderie and spirituality are part of the process or the only part a patient needs they offer it. My point in this piece is that this patient really was placed in Hospice because of the feelings of his facility nurse advising a distant but caring and distraught family. The palliative care team out of one Hospice was professional enough to admit there was nothing to add at this time. The other agency rolled out the care team when it was probably a bit premature and at the same time billing Medicare for their services. Multiply this situation by the thousands we have in our senior citizen rich state and you see why Medicare’s expenses in the last few weeks of life are so staggering.

        • Marianne Evans

          Yes, but I don’t think most of that is Hospice. I think most of that is ineffective and futile ICU care, chemotherapy, etc. Also I don’t know about Florida but in my state ( Maryland DNR certainly does not mean do not treat or hospitalize, and in my experience, very few nursing homes are prepared to provide comfort care to a dyspneic, agitated, cyanotic patient without the support of Hospice. And if you wait until the patient is actively dying to call Hospice, the patient will die before they are admitted.

          There certainly has been fraud and abuse particularly in the profit sector, and Medicare has recently stepped up its oversight of patients with non-cancer diagnoses, especially in nursing homes. That is why when I have my IDT meetings, I insist that each and every patient continues to meet criteria and to have an appropriate care plan. The chaplain and social work services by the are REQUIRED by Medicare as part of the interdisciplinary approach to the dying patient. Despite my own religious skepticism, I find the Hospice chaplains, who have special training in end of life care, often provide more comfort to patients and more insight into the nature of patient’s suffering than any other team member.

          • Marianne Evans

            By the way Dr. Reznick, thank you for continuing to care for your dying patients. Many physicians just turn them over to me, and I am happy to see them, but sad to see the dissolution of the bond between the patient and the family doctor.

          • Steven Reznick

            The medical care system is being changed to prevent longitudinal care. If the Zeke Emmanuel’s and Bob Wacheter’s of the world have it their way , medical school and residency training will be shortened and we will train outpatient and inpatient docs with a narrow but thorough area of expertise. There will be no long term relationships or longitudinal care. That is not the way I was trained or raised. My patients entrusted their care , health and lives to me. It is my responsibliity and duty to make sure their wishes are carried out to the end in a caring and compassionate way. In the past Hospice helped greatly as a partner in end of life care. With so many physicians just turning the care of their end of life patients over to Hospice they get confused when a clinician wishes to continue proviproviding care.

          • MELVIN RAY

            Marianne, Thanks for clarifying your understanding of the clinical interventions of professional Board Certified Chaplains. Contrary to popular belief, we healthcare chaplains are health care providers (if board certified), not religious workers representing some self appointed theology. Everyone has a spirit, not necessarily reflected in an organized religion (see Dr. Reznic’s input). As you indicate, the outcome of the services provided are positive in making patients and families more healthy – and that includes the best possible living at the end of life. Melvin Ray

    • Steven Reznick

      Patient has executed a yellow state of Florida DNR form which would eliminate the 911 trips to the ER. In my recent experience when a patient meets with the Hospice admission team and the patient, physician and family define the parameters of care, the care plan that is executed by the team assigned to that patient turns out significantly different. In addition, if the referring physician wishes to stay involved in the oversight and care process, the communication has not been there. I have set up meetings with the directors of our local Hospices to correct this and we have corrected it but that should not have been necessary. The spiritualism of Hospice is truly wonderful but the patient and family have to agree to participate in it and want it. Hospice has very much become a business, funded by Medicare dollars which carry with it less flexibility and far more bureaucracy than they once had.

  • Harry

    The government didn’t USED to have to use taxpayer dollars to provide spiritual care for the dying, because people would have been long-time members of congregations which would have stood by them and filled that role without the GOVERNMENT needing to get involved.


    • Patricia

      This is a bit narrow sighted reply to this issue. If you think about it, the tax exempt status of the business of religion IS a government subsidy. And not everyone is religious nor should they have to be in order to have appropriate end of life care. Your comment is filled with logical flaws.

  • bill10526

    My ex-wife did hospice work for a while. We attended many wakes during that period One fellow was in the bed next to the kitchen, and he was feeling sorry for himself. My wife told the family to go shopping and leave her along with him. She changed his bed, washed him up, and gave him a shave and haircut. The family returned and found the man to be in a good mood. They then had complete confidence in my ex. She was a wonderful woman in many ways It occurred to me that the family wanted to do right by their loved one, but they were not sure what right was.

    One woman wanted to do all for her husband who lost his reasoning ability for eating. He was fed through a tube with a milk shake concoctions. His diaper was then changed some time later. Clearly that was not living, but the wife wouldn’t let him go.

    I am rambling. My point is that family members have to be supported in making reasonable choices so they don’t feel their love one is being abandoned..

  • Patricia

    I think that what is happening here is that we, as a country, do not have non-politicized solution based conversations on how to deal with this problem. The nurse isn’t “wrong”; she is doing what she has been trained to do~ care for her patient. The doctor isn’t “wrong” either. We don’t like to think about end-of-life in this country and we leave it open-ended without analysis. Sure that analysis has to consider the costs. It must consider costs. But it also must consider the needs of individuals. We should be looking at how other countries handle this. And as you know this is just the end point of the lousy health of American citizens. We really need to work upstream and solve these problems. Again, looking to other successful countries would be extremely helpful.

    • Guest2

      Flawed as our system may sometimes seem, I still prefer it to a UK-style system where the NHS decides which patients to put to death, and in at least a third of cases doesn’t even bother to inform (let alone seek consent from) the victim’s loved ones.

      • Patricia

        I would like to see actual sources that reliably cite this because I find it hard to believe. We should look to Sweden for example for good practices since they are healthier and live longer than we do. Health care is just a part of the picture but I am willing to be that they have a better system for dealing with end of life care.

        • disqus_exm7iYxntF tlo

          There has been mounting concern in the UK over cases in which family members said they were not consulted or even told when food and fluids were withheld from their loved ones.

          Last December, the Health Minister pledged to strengthen laws to protect patients, making it illegal to put them on the “Liverpool ‘Care’ (Death) Pathway” without consulting them or their families.

          Jeremy Hunt, the Health Minister, brought these disclosures up in Parliament last year. They were from a recent audit of the “Liverpool Care Pathway”.

          • In 44 per cent of cases when conscious patients were placed on the pathway, there was no record that the decision had been discussed with them.

          • For 22 per cent of patients on the pathway, there was no evidence that comfort and safety had been maintained while medication was administered.

          • One in three families of the dying never received a leaflet they should have been given to explain the process.

  • Robert Luedecke

    It is fortunate this patient has a caring doctor and caring nurse. I must disagree that the care this patient is getting is a waste of Medicare resources. The end-of-life care that uses up 25% of total Medicare dollars is ICU/ventilator/invasive monitoring/cardiac pacing in someone who is ready to die. The efforts of this nurse and family to help in any way that is reasonable is not only appropriate, but laudable.

    • Guest2

      “The end-of-life care that uses up 25% of total Medicare dollars is ICU/ventilator/invasive monitoring/cardiac pacing in someone who is ready to die.”

      The patient already has a living will and a DNR designation. You don’t have to turn your care over to a for-profit hospice provider to be able to do this.

    • Molly_Rn

      The nurse is treating herself and has lost her focus. She should be supporting the patient who clearly has made his decision.

  • meyati

    This should be about patients’ rights. The patient was comfortable and didn’t want the tests or a change in protocol. The tests showed that he didn’t need to have a change in protocol. I filled out 5 wishes-and they didn’t like it. They called me in to do it again- and we fought about each of the 5 wishes. Fortunately, I had a 26 year old grandson with me. I filled it out the same way. They didn’t like it that my 26 year-old grandson is my agent. They didn’t like it that I didn’t want my family ordered into counseling. They didn’t like it that I wanted some stupid stranger telling them they needed to forgive me, and I love them, blah, blah, blah. I don’t want to be tubed for over 3 days-unless I can get up and vacuum the house. I don’t want to be in a coma forever-3 days max-I’d like the dignity of going when it’s time. There’s more to living than having a beating heart. They also got mad that I said-I want all the dope you can give me. They said your mind won’t be alert- I asked if I was in extreme pain-why should I want to be alert-scumbags—I have good doctors now–they understand this. Now to walk my coonhounds-and get ready to meet the chaplain to talk about the problems of EMTs ignoring a DNR. I have friends that filed complaints because the DNR was ignored-the nurse ignored their father’s wishes and called the EMTs-they fired her rear-end in a hurry. Their poor father-came to and was bellicose that he was still alive. He didn’t do anything to endanger his life.

  • Guest2

    “He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.”

    I don’t understand why a well-crafted living will and a proper DNR designation, along with a caring and understanding primary care doctor, couldn’t fulfill most of the same practical goals of hospice. The complaints about expensive “ICU/ventilator/invasive monitoring/cardiac pacing” brought up here wouldn’t apply to this patient if their advanced directive & DNR excluded them, would it?

    If a patient is well cared for by their regular doctor who understands end of life issues, I don’t see why they should necessarily be pressured to transfer their care to a hospice team.

  • Suzi Q 38

    The comment I want to make has a different “twist.”
    My FIL, who was in his 80′s, had had multiple strokes and had lived for the past 12 years with one health problem or another.
    Finally, he decided that he was not going to get the dialysis he needed to stay alive.

    The nurses at the nursing home really wanted him to do it, but he didn’t want to.

    I think that part of the deal is that the nurses, understandably, get emotionally attached to certain patients. they care about them. In this case, the nurse means well.
    The other thought is that maybe the additional care ordered by Medicare B made the nurses’ job easier. Of finally, they like having this patient as a paying customer.

    At any rate, it is the patient’s decision.

  • Maggie Beaumont

    Sometimes the family and the nursing home have different understandings of what is meant by DNR.

    Nursing homes send people to the local ER in case the patient needs an IV – say, for simple dehydration. DNR doesn’t come into it.

    We also have incomplete understandings of how Hospice works, and how Medicare pays for it. When my mother went on Hospice, we got excellent value from the palliative meds, the nursing visits, the volunteers, the patient-education and family-education, and afterwards the grief group.

    But we also got: a commode, a walker, and a folding wheelchair that duplicated equipment she already had; and several chaplain visits that she routinely refused, having a great relationship with her chosen pastor. Medicare paid for all those, too.

  • Molly_Rn

    Ask the patient and follow their wants. Remember out of state kin can feel guilty and think they are showing their concern by asking for more “care” than the patient wants. I have warned my family that I will come back and haunt them.

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