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Outside editorial: Have you had the end-of-life discussion?

Posted: January 17, 2012 - 12:00am

The following editorial appeared in the San Jose Mercury News:

Americans need to change the way they think about death and dying.

The United States spends about $70 billion a year — one-third of all Medicare expenditures — on medical care for the elderly in the last months of their lives. If money for health care is going to be limited, and we know it is, then we need to think and talk about whether this is the right place to be spending so much of it.

The Republican candidates for president all are promising to repeal President Barack Obama’s health care reforms, which may or may not sit well with people already benefiting from health insurance because of them. What the candidates — and the president — should be talking about instead is how to get medical costs under control so that all Americans can receive better care with the money available. Part of that has to be a serious exploration of what Americans at the end of their lives really want and need in the way of medical treatment.

And please, don’t even breathe the term “death panels.” No one in their right mind wants to kill grandma and grandpa, certainly not anyone running for public office. But we do need a better way to determine the right amount of testing and treatment appropriate for elderly patients.

While life expectancy of some people is not hard to gauge — late stage cancer patients, for example — doctors now lack accurate tools to predict a patient’s life expectancy. But a new study published Tuesday in the Journal of the American Medical Association may help further that discussion. The New York Times reports that researchers at UC San Francisco “have identified 16 assessment scales with ‘moderate’ to ‘very good’ abilities to determine the likelihood of death within six months to five years in various older populations.”

The measures are things like age, medical history and physical and mental abilities. With further research, the hope is that doctors will be better able to assess whether a certain test or treatment is appropriate to extend life or improve the quality of a patient’s life in final months or years.

Obama and the Republican candidates should encourage study in this arena to help bring down medical costs as well as foster humane end of life care. They should be encouraging Americans to talk with their loved ones about how they want to spend the last months of their lives and whether they want extraordinary measures used to prolong life. When people don’t write advance directives or give explicit instructions to legally responsible family members, doctors are placed in a difficult position. They feel obligated to offer tests and treatments that they may believe to be pointless. Hospitals can be forced to provide aggressive, expensive but ultimately ineffective treatment when patients could be more comfortable in hospice care.

Research already shows that elderly patients who fully engage in end-of-life discussions with their doctors and families choose less aggressive treatment. They also experience less depression and an improved quality of life for them and their families.

The United States will spend nearly $2 trillion on health care this year, a level nearly double the per-capita rate in Europe. This is 17 percent of the U.S. gross domestic produce and growing. We cannot sustain it, especially when our chief competitors in the world economy are spending considerably less and in some cases getting better overall results.

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