Dying, never easy to confront, has become still more difficult in the era of high-tech medicine. The end of life often comes after repeated surgeries, a retinue of drugs with painful side effects, endless consultations with specialists and being harnessed to life-supporting hospital equipment. We have become so adept at prolonging life that death often arrives after months or years of coping with not just one but several severe ailments.
Many patients would choose not to extend their life this way, but modern medicine does not help them with this crucial decision. The nonprofit Institute of Medicine's report Dying in America, published last September, found that the vast majority of people in the U.S. have never had an end-of-life discussion with a health care provider, or even family members, about trade-offs between extra days and extra comfort. Straightforward changes to medical training and incentives would bring a healthy improvement to a sad situation.
Only 6,500 physicians are board-certified in hospice and palliative care, the specialty focused on pain relief and end-of-life care. That number is between 6,000 and 18,000 fewer physicians than we need, according to a 2010 estimate. The best way to fill these gaps is to train a broad swath of health care professionals—generalists, specialists, nurses and physician assistants—in this kind of medicine. At present, medical schools spend too little time on the subject. Every student should receive extensive grounding in how to treat pain, breathing problems and depression and in how to preserve mental faculties. Students should be required to practice interviewing patients and family members about their desires for care—questions that go beyond asking whether patients wish to be kept on a ventilator if their health deteriorates.
It is especially important to learn to have “the conversation”—the careful and honest interaction between doctor and patient to plan the best course when options look bleak. After this discussion, which can also involve the family, a patient might decide to forgo yet another debilitating round of chemotherapy and instead focus on remaining mobile and comfortable enough for a few months to attend a granddaughter's wedding. Or the patient might want to press on with treatment at all costs. Either way, personal values, not technology, should determine these choices.
Skills in helping patients to navigate life's final stages also need to be tested after they are taught. Right now only 2 percent of the board-certification examination for oncologists, for whom palliative medicine is clearly relevant, is devoted to end-of-life care. Before getting a license to practice, any provider, not just cancer physicians, should prove competence in this vital area.
Better education is not the entire answer, however. Money matters, too. Physicians will help more with end-of-life planning when government and private insurers reimburse them for their time. These discussions have not been covered under Medicare, and the Centers for Medicare & Medicaid Services has moved much too slowly on plans to add such reimbursement.
Palliative care has shown its worth. Several studies during the 2000s suggested that such care might increase patient survival compared with standard practice, possibly because it reduces patient depression and high-risk medical procedures.
The upside extends to the health care system's bottom line. Diane E. Meier, a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, noted in a 2011 paper that palliative care, at its current level of penetration in U.S. hospitals, saves $1.2 billion annually over standard care—a figure that could rise to $4 billion a year if implemented at nearly all hospitals. The savings, in part, come from avoiding unwanted procedures.
Ultimately the reasons for making these changes go beyond any hard-nosed cost-benefit analysis. Careful consultations among doctors, patients and families add compassion that is often missing in medicine. “Technological society has forgotten what scholars call the ‘dying role’ and its importance to people as life approaches its end,” writes Harvard University physician Atul Gawande in Being Mortal, his 2014 book that is still high on best-seller lists. “People want to share memories, pass on wisdoms and keepsakes, settle relationships,” he adds. “They want to end their stories on their own terms.” When health care providers help patients attain this, everyone regains a measure of humanity.