End-Of-Life Costs

Wednesday, July 01, 2009

In his recent interview with the New York Times's David Leonhardt, President Obama said that a key step to health care reform will be having a "very difficult democratic conversation" about the high cost of end-of-life care in the United States, which accounts for up to 80% of health care costs. Judy Bacharach, columnist at Obit Magazine and The Checkout Line, imagines what such a national conversation would look like.


Judy Bacharach and David Leonhardt

Comments [31]

Rachel from New York

I am shocked by the "group think" expressed here, that almost to a person, everyone advocates "death with dignity" and other such euphemisms. This is all but one step away from murder! The next step will be euthanasia due to "the high cost...". To be sure, the reasons given will seem so logical as to irrefutable.

Have we lost our moral compass? Are we to neatly dispose of the elderly due to some convenient rationalization?

Life is sacred. We are not at liberty to say who will die and when. People who are in a frail medical state can easily be pressured and manipulated into agreeing to "pass on" at a designated time.

Unfortunately this is yet another manifestation of the triumph of money over human life. Yes, the medical profession, encompassing doctors, hospitals and the insurance companies is the epitome of greed; both as things stand now - what with unnecessary procedures - and also under the proposed new system. Only then, the medical profession will stand to profit by withholding treatment as it sees fit.

We have surrendered our health to the medical professionals and are thus subject to their decisions; we must reclaim our health through a healthier lifestyle and better knowledge of how to heal ourselves. Let us remember that there is a G-d who runs this world. We are not in charge of deciding who lives and who dies.

Jul. 01 2009 08:51 PM
Joanne from West Orange, NJ

Difficult and important topic! I think it falls into the category of you really don't know exactly how you feel until you experience it personally. I wonder, who do we trust to determine the definition of "end of life"? The doctors who are human and sometimes wrong, the patient who wants to continue the fight, the families who are trying to maintain a sense of control? I also wonder how the conversation might shift when talking about a child with an illness where life expectancy is questionable. What about all the premature newborn babies who hang on the brink of life at birth, or the severely disabled? I would not want the politicians to determine what constitutes a "quality life".

Jul. 01 2009 03:38 PM
rabi from NJ

Who does it benefit for the end-of-life patient to be kept "alive"? The medical profession? To assuage guilt of family and friends?

Why is medical care so expensive that insurance is needed to pay for it? If because of malpractice insurance costs, do the number of malpractice suits justify the high fees to providers?

Provider hourly fees and hospital charges should be no more than 10 times the minimum wage so that patients could afford to pay fees without insurance---if the many layers of insurance and its support staffs/services were removed from the "picture", care would be more affordable. This is a factor in why it is less expensive to go abroad for medical/ dental, etc. treatment.

It has not been mentioned that most Medicare recipients also have Part B, at a cost of @$100 per month, so all that money is going back into Medicare and is not free to patients. Doctor charges to Medicare are unreasonable.

Jul. 01 2009 03:12 PM
Eugenia Renskoff from Williamsburgh, Brooklyn

Dear Brian, When my father was dying of cancer almost 24 years ago, the doctors did everything they could to make his last days tolerable. We were living in San Francisco and had Kaiser Permanente health insurance. There came a time when morphine was the same as water. It didn't help alleviate his pain at all. Nevertheless, as far as I can remember, the doctors were very kind.
Now, I have no health insurance and am in need of dental care and a doctor to treat my chronic back pain. Because I am unemployed, I cannot pay insurance. I am seriously considering going to Argentina, my country of origin, to get the treatment I need. Although Argentina is not a perfect country, most public hospitals are very good and will treat a person living in the neighborhood or county for free. Eugenia Renskoff

Jul. 01 2009 01:57 PM
dory from New York, NY

I am a Palliative Care Social Worker caring for people with terminal illness in the hospital. Good care at the end of life does not necessarily mean expensive care. Good pain management, emotional support to patient and family and bereavement services to families cost a lot less money than expensive and life prolonging treatments that do not necessarily enhance quality of life

Jul. 01 2009 01:41 PM
NABNYC from Southern California

Much of the medical care given to seniors is unnecessary, not likely to extend their lives or make them better. Instead, it is the for-profit greedy doctors and hospitals that push treatment and procedures on old (insured) people in order to make more money.

I have two attorney friends who work in the elder abuse field, and they both have told me nightmares about enterprising young doctors recommending a variety of operations for very old people obviously at the end of life. It is appalling. I personally knew a woman who was in her 80s with heart failure, emphysema, crippled up with arthritis, unable to live independently. During the last two years of her life her doctor did 3 separate operations on her: one on each knee, and a hip replacement. She had them done, but what was the point other than to make a lot of money for the Medical Industry?

I know another older woman who broke her ankle, and when she got to the hospital they ran thousands of tests on her, "found" other problems, recommended other treatments. Instead of just putting the pin in her ankle, they turned her into a $100,000 payday. They kept her in the hospital long enough to give her a deadly staph infection, which killed her. It is criminal.

These end-of-life treatments for old people are rarely for experimental efforts to cure cancer. It's just cash-register medicine.

Jul. 01 2009 11:51 AM
jawbone from Parsippany, NJ

Cont'd from 24 above--

Only 19 more months until I qualify for Medicare and I can go to the cancer specialist of my choice and rec'd by my other doctors, instead of the best among those in my HMO. Maybe then my version of one of those "good" cancers can be more effectively treated. Right now --formerly paying $1500 plus copays, deductibles, 50% of prescription costs each month and when it went up to nearly $1800 per month, I opted for double the copays, higher deductibles to bring it down to just over $1000 per month-- I can't afford to go out of plan for more expert opinion. This good cancer's remnants are supposed to be slow growing -- may it be so.

Rationing? Since there is remnant tissue which might be spreading my cancer, expensive scans should be part of the monitoring treatment. And I did have one round of those. Now, the insurance company makes it so difficult for the doctor to get these tests he said we should "wait and see" if something shows up on the less rigorous test. My own microscopic Sword of Damocles.

Health insurance with high copays and deductibles is almost a protection racket, and not protection of the insured's health but of the insurer's bottom line. It is necessary to prevent ruin from catastrophic health care costs. But some of these plans, with their high decuctibles and copays --and caps?-- mean the person is merely putting off bankruptcy.

"Nice little house" or "Nice little savings you got there; too bad if something should happen to it."

Why keep feeding the insurance parasites? 30% of each health care dollar paid to them going to overhead, marketing, denial of care bureaucracy, very high executive compensation? Medicare -- 2-3% of care dollars go to overhead. Gee, think, Mr. President, of all those savings!

(Yes, smaller insurers will donate smaller amounts, that is true. But what's best for the nation?)

Single payer, Medicare for All.

Jul. 01 2009 11:15 AM
jawbone from Parsippany, NJ

The problem with end of life cost discussions is that when the life doesn't end the expensive measures aren't included in the "end of life" statistics. Right?

True story: Family friend in her late 60's/very early 70's developed a very serious health issue. She was in criticial care in the hospital for weeks, and her doctor brought in several specialists and all agreed: she was dying. Nothing more to be done.

This family was old-fashioned in the extreme in terms of privacy, but the dying woman's sister was a bit more sharing of knformation, and told us that she took extraordinary measures to find other medical opinions. I never did learn the diagnosis, alas.

The sister eventually another specialist who thought the dying woman's diagnosis was not correct. He took on the case, developed a diagnosis which was correct, and the dying woman was brought back from the brink of death to her usual health. Since she had lost so much weight, she was weak for a long time, had little energy, and felt more vulnerable. But eventually she came back to her usual verve and strong personality.

She died in her early 90's essentially of old age.

Had she died of the illness of which I do not know the name she would have been a statistic in the "highest cost to healthcare system in last x-months," right?

That's when I realized my HMO could be the death of me, as I and my family have such limited choice in doctors and especially specialists.

Single payer. Medicare for All. And this comment @ 6 above:

Nora Freeman. July 01, 2009 - 10:22AM
How about instead of framing the discussion as: the elderly competing with the young for resources, instead we frame it as: people competing with insurance companies for resources? How would that affect the conversation? Keeping in mind that we are already rationing health care.

Cont'd below.

Jul. 01 2009 10:55 AM
Caitlin from Jersey City

Why don't we add "do not resuscitate" (or, "DO resuscitate") to driver's licenses, just like organ donor status?

Jul. 01 2009 10:54 AM
Hannah from Brooklyn, NY

This was a very important discussion. Thank you for hosting Brian. I wanted to let people know of the How We Die project. They are collecting first-person stories about decisions and conflicts people face at the end of life. The stories reflect a lot of what was discussed on the show today:

Jul. 01 2009 10:49 AM
Inderpal Chhabra from Queens

The idea that we have to ration care is contrary to the way our society thinks. If a surgeon tells a person you do not need surgery, they just go to the next person who does it. And the idea that doctors make money off of dying people is LUDICROUS.Medicare pays the same amount for each day and some HMOs actually pay a set amoount per hospitilzation, no matter how long a person is hospitalized.
Once individuals come to grips with the fact that the Society as a whole pays each time you ask for extra services or procedures for your dying mom, which, your doctor knows is not going to add to the life span, then we can talk about really changeing the system. Frankly, I am just to scared of being hit by a lawsuit each time I advise taking away care for a dying person. I have to tread extremely carefully on this issue.

Jul. 01 2009 10:45 AM
Lindsay Pearson from Manhattan

The reluctance of country to provide only (but excellent) palliative care near the end of life, combined with today's headlines on banning two pain killers: Vicodin and Percocet, along with previous restrictions on medical pain killers make me question whether this is a medical issue at all.
I see this, excuse me..hypocritical, "protection of life" as a political issue: the imposition of a religious and punitive stance on people of a different belief. Why can we not have a choice? I personally hope at the time of my death that euthanasia will be legal.

Ironically, the issue may be settled by our current economic deficits.

Jul. 01 2009 10:43 AM
Nora from

Another comment, from my personal experience: my father died a few years ago. He had Alzheimer's disease, and unlike most such individuals who mercifully succumb to other problems before the final stage, my father went on to the bitter end. A feeding tube sent in nutrition and hydration which his digestive system, severely taxed by gastro-esophageal reflux disease, routinely rejected, causing alarming fits of coughing due to his seriously weakened swallowing mechanism. I did not and still don't believe that he had any meaningful quality of life for at least the last year of his life. He himself, had he known what was to become of him, would never have agreed to it, but my siblings were adamant on continuing. The resources that were expended from my parents' savings to keep this going are now not available to his grandchildren for their education, another thing that would have horrified him had he known. What's wrong with this picture?????

Jul. 01 2009 10:42 AM
Terry B. from Inwood, Upper Manhattan

I caught the end of this program today. Brian responded to the poster who commented that Medicare does not pay for hearing aids and con-trasted this with the large amounts spent on end-of-life care. Brian called this an important quality-of-life item. But it might
be a life-saving item both for safety from traffic and bicycle riders as well as helping with socialization which has been shown to help maintain physical and mental health.

Jul. 01 2009 10:39 AM
Tf from 10075

everybody dies there's no reason we can't make a profit off the process.

Jul. 01 2009 10:38 AM
Mary Madsen from Brookly NY

I have been a nurse for 27 years and have spent many of the years working in ICU caring for patients at the end of life. Almost daily we would resuscitate a dying patient and remark afterward "he will live to suffer another day".
Family members are asked to make the decision to keep or not to keep a family member alive (signing a do not resuscitate order) at a time when they are under tremendous stress and often have feelings of guilt. They are in no condition to think rationally. I think it would relieve some of the pressure on families if these extraordinary lifesaving measures were simply not available under certain circumstances. I do think the government needs to step in.

Jul. 01 2009 10:34 AM
Eleni from NYC

Firstly hospitals are NOT hospices.
My mother had terminal cancer, in the end of her last 11 days of her life in a bed at Memorial Sloane- Kettering, her back had broken. The idea of giving her a surgery for a broken back would be cruel. Some hospitals like MSKCC have floors that are dedicated for patients in their final days. MSKCC also encourages the families to sign papers for DNR: Do Not Resuscitate for humane reasons.

Jul. 01 2009 10:31 AM
Jessica from long island

Rationing is not just to who, but what we will and will not pay for. Medicare/Medicaid would not pay for more than 30 days of physical therapy when she went to a nursing home, but they have now both been paying for almost 7 years!! to keep her alive with feeding tubes and medications and round the clock coverage.

Our priorities are in disarray. Perhaps if we encouraged a better quality of life through exercise, we wouldn't have to pay as much for living through pharmaceuticals.

Jul. 01 2009 10:31 AM
Tom from Westfield

No one seems to be talking about the implication of the legal system, defensive medicine on costs


Jul. 01 2009 10:27 AM
Neal from Manhattan

Is there something different in American culture that makes us emphasize life, regardless of the quality of that life?

Jul. 01 2009 10:25 AM
JP from The Garden State

There’s a huge discrepancy with the old and sick being insured and the young and healthy who are not insured. The young and healthy that are uninsured need to be offered cheap healthy insurance. This would help balance money going in and money going out. Many have argued this would make up a lot of ground for helping pay for the old and sick who are insured and taxing the system.

Oh and Medicare only pays about 70% to 80% now so this lady is smoking out of her rear if she thinks any doctor makes money off of Medicare. Medicare does not even pay thier bills....

Jul. 01 2009 10:24 AM
abf from NJ

Death is waiting for all of us. We must learn to accept this. There is a huge difference between living and merely existing. I have seen this terrible, drawn out, expensive end of life process with many elderly relatives. They die in hospitals, where they did not want to die. All wanted to be at home with family when the time came to pass on. We need to let go of the idea of just keeping someone alive. An aunt of mine is now in a nursing with severe Alzeimer's and other complications. She recognizes no one from her family. She is in a wheel chair. It costs $72,000 a year. This is not a good solution.

Jul. 01 2009 10:24 AM
ethel Romm from ny, ny

I'm 84. When I explained to my doctor that I wanted no extreme measures taken at the end of my life, he asked,

"How is your relation with your kids? The only time I ever see a problem is when a son or daughter, who hasn't kept in touch for years, shows up and out of guilt accuses everyone of mistreating mom. "You haven't called the top lung doctor. I will. And we need x, y, z."

Jul. 01 2009 10:23 AM
mombi from NYC

It's not only end-of life for my 97-yr-old grandmother. Some 25 years ago as a young wife and mother to a 2-yr-old, I had to work to honor my husband's "no extraordinary measures" directive when he lay dying of a brain tumor at only 33 years of age. It is instinctive to hang onto our loved ones even when it is only a shell of them. My mother-in-law had some difficulty with it but ultimately appreciated that my husband and I had discussed this before it came to the choice and she was glad I was able to respect with his wishes.

Jul. 01 2009 10:23 AM
Rich from New Jersey

My Dad passed away, at 90, of cancer. Though he had superb health care/hospital coverage, he was cared for at home with the assistance of a home health aid and hospice. The focus was pallative and pain management to ensure he was comfortable, which he was. As was pointed out by a guest, he wanted a "good death" not more days breathing. Hospice should be an option offered all at the end-of-life. Hospice allowed him to be at home and out of the hospital and no-doubt saved the many thousands which could have been spent.

Jul. 01 2009 10:23 AM
Nora Freeman

How about instead of framing the discussion as: the elderly competing with the young for resources, instead we frame it as: people competing with insurance companies for resources? How would that affect the conversation? Keeping in mind that we are already rationing health care.

Jul. 01 2009 10:22 AM
hjs from 11211

people need to tell their kids if at the end of life they want quality of life more than quantity of life.

Jul. 01 2009 10:21 AM
Andrea Kott from sleepy hollow, ny

I am a journalist who specializes in end-of-life care. How doctors are trained must be part of the conversation. Our culture still instills in doctors a paternalistic approach to medicine: one that says a patient death is a doctor's failure. And patients take their clues from doctors. Once the medical establishment learns that letting go with dignity is respectable and appreciated, then patients will begin to have permission to see their own lives -- and deaths -- differently.

Jul. 01 2009 10:19 AM
Charles Harris from Island Heights NJ

consider outsourcing patients to nearby countries that offer good care at lower cost

Jul. 01 2009 10:13 AM

A good start would be to simply educate people about the options available for living wills so they can make those decisions for themselves. There are organisations that provide free assistance in making and filing these documents. I for one never want to have my life extended if there is no hope for recovery. And I have made it clear, and set it down legally

Jul. 01 2009 10:13 AM
Charles Harris from Island Heights NJ

One possibility is that for ceretain end of life, long term comatose etc, coma center patients, consider outsourcing patients to nearby countries that offer great care at less cost.

Jul. 01 2009 10:12 AM

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