Medical ethicists still debate how to best communicate end-of-life options to patients. But some states, such as New York and California, mandate that physicians start the conversation and offer information on palliative care designed to improve patient comfort. Such discussions could also reduce costs. In a 2009 study, Prigerson's team found the cost of care in a patient's final week was $1,041 (35.7 percent) less, if he or she had an end-of-life discussion with doctors.
A reluctance to discuss end-of-life decisions may lead to care that is too little and too late. Half of all adults older than 65 years of age made an emergency room (ER) visit in the last month of life, according to a study in the June issue of Health Affairs. Data from the Health and Retirement Study was linked to Medicare claims to track ER use and death. Three quarters of the emergency visits led to hospitalizations and of those admitted, two thirds died there.
Hospital emergency departments focus on triage and stabilization and are not equipped to deal effectively with patients near the end of life due to illness or age, says Smith, the study's lead author. The visit comes at a time of crisis for these patients and their family members, he explains. Many are not prepared for the end of life. For instance, only 10 percent of the study participants were enrolled in hospice care. "We've come a long way from where we were 10 to 15 years ago," Smith says. But, he adds, clinicians need to develop more robust palliative care programs and focus on care outside the hospital, such as in doctor's offices and in the home.
Improvement on the way
One of the topics physicians could and often do discuss is palliative care, which offers relief and comfort, such as medicine to tame nausea. Large hospitals are most likely to have palliative care teams, finds a 2011 report from the CAPC. The report gave the nation as a whole a B grade—up from a C in 2008—observing that less than a quarter of all states still need significant improvement. However, there is only one palliative care specialist for every 1,200 people living with a serious or life-threatening illness in the U.S. compared with one oncologist for every 141 newly diagnosed cancer patients. Additionally, only 54 percent of public hospitals provide palliative care.
That access could be extended under the Patient Protection and Affordable Care Act of 2010 (pdf), recently affirmed by a Supreme Court ruling, says Kathy Cerminara, a law professor at Nova Southeastern University in Florida and an expert in law governing treatment at the end of life.
Two provisions in the act explicitly address hospice care, a common way for patients near death to receive palliative services. The first provision authorizes the secretary of the U.S. Department of Health and Human Services to fund a study determining whether patients in hospice programs would benefit from offering curative and palliative care simultaneously (For now, hospice care typically requires patients to forgo curative treatment in order to enroll.)
The second provision is likely to challenge rural health providers, an already struggling sector, according to the palliative care report card. The provision requires reevaluation for any patient remaining in hospice care after six months. Hospice programs that show a high rate of reenrollment can face review and potential fines. Medically underserved areas, including rural stretches of many states, struggle with short staffing and a lack of hospice providers already, Cerminara explains. Requiring face-to-face encounters for patients hoping to remain on hospice may prevent professionals from recommending service in the first place. "Congress has a good goal in trying to prevent fraud and abuse, but they're doing it in a rough way," Cerminara says.