Saturday, April 4, 2009

Less Is More

So far I've stuck with stories about patients, but I wanted to write about a fascinating recent study that is all about the work of caring for those at the end of life.

Publishing last month in the Archives of Internal Medicine, researchers in Boston posed this question: would it make a difference -- financially or in terms of quality of life -- if cancer patients had a frank discussion with their doctors about their preferences for care at the end of life? Well, it makes a big difference. Patients who'd had the talk were less likely to be admitted to or die in an ICU in the final week of life. They were more likely to enroll in hospice early and more likely to receive hospice care in their homes -- which is what hospice is designed to do. They had less physical suffering and higher quality of life in the last week of life than cancer patients who hadn't had the conversation with their physicians.

And they were less expensive, too. Costs of medical care in the last week were around $1000 less for those who had spoken with their doctors about their preferences for comfort care instead of life extension regardless of the cost in suffering.

By the way, the two groups of patients -- those who talked, and those who didn't -- lived for the same amount of time.

So spending more money in the final week of a cancer patient's life doesn't lengthen it but does worsen its quality. Counter-intuitive? Not really, I think.

For everyone concerned about the high cost of health care, the study contains a remarkable projection. Of the cancer patients interviewed for the study, about 30% had talked about their end-of-life preferences with their physicians. Here's the researchers' amazing conclusion:
If the national proportion of individuals reporting EOL discussions was increased to 50%, our results suggest that we would expect a cost difference of $76, 466, 891 between individuals who had EOL discussions vs theose who had not based on the total number of US cancer deaths per year.
In other words, we could save over $76 million a year -- not to mention untold amounts of agony -- by the simple act of getting cancer patients and their doctors to talk with each other about the end of life. Just talk, and the result is better quality of life and reduced cost in the last week of life. Not every innovation in health care is complicated. Sometimes less is more.

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