Eventually, no matter how much prevention and treatment of
illness we practice, everyone will die. Expensive technologies that
may save lives and restore health in other circumstances frequently
increase suffering and prolong our final days. As a society, we
expend huge sums of money that do not improve care or quality of
life but that frequently cause greater suffering for patients and
their families. Physicians, especially those who treat the
terminally ill, must discuss these sometimes-painful issues with
patients and their families, develop a plan together, then follow
the patients' wishes as the end comes.
Texans must ensure that our spending on health care resources
during patients' final days, weeks, and months matches their
individual desires.
As our population ages, so too does the number of individuals
with chronic illness. Approximately 132 million Americans today
live with chronic illness. That number should jump to more than 170
million in the next 25 years. Since nearly all patients die during
the course of a chronic illness, death rarely takes us by surprise
and preparation is possible.
Until the turn of the 20th century, almost all Americans died at
home. Today, 98 percent of Medicare patients spend at least some
time in a hospital during the last year of life, and 75 percent die
in a hospital or nursing home. But about 70 percent of patients say
they wish to die - like their great-great-grandparents - at home.
We have an immense gap between patient preferences and reality.
There is significant data showing that improving care at the end
of life is quite possible and decreases costs. Of the $247 billion
Medicare spent in 2002, more than one-quarter - $64 billion - came
during the last 12 months of patients' lives. More than half of
that amount - $35 billion - came during the final two months.
Counting all funding sources, we spend about 22 percent of our
health care dollars in the final year of life; that's a total of
$330 billion for the 2.4 million Americans who died in 2002.
The medical literature is not conclusive as to the potential for
significant cost savings at the end of life. Studies do show three-
to six-fold variations in spending among the best hospitals in the
country in the last six months of life, independent of severity of
illness or outcome. And we know, conclusively, that it costs
significantly less to die with appropriate hospice care at home, in
a nursing home, or in a standard hospital bed than in the intensive
care unit.
It is a Texas physician's responsibility to consult an ethics
committee if a patient or family member asks for life-sustaining
treatment that the physician does not believe will medically
benefit the patient. In some cases, even if the ethics committee
agrees with the physician that the requested care is futile, state
law requires the physician and hospital to provide care for 10 days
while attempting to find another physician or institution that will
provide the treatment requested. It is undoubtedly in everyone's
best interests to avoid such painful conflicts.
To improve the quality of Texans' final days, TMA
recommends:
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Improving communications about the goals and likely outcomes
of medical care. Building off of the success of the Texas
Advance Directives Act, we should insist that physicians,
patients, and their families incorporate advance care plans
into standard chronic patient care and acute crisis care.
Physicians, patients, and their families should discuss an
advance care plan every time a patient is admitted to an
intensive care unit by choice, i.e., after major surgery.
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Requiring medical schools, with appropriate funding from the
legislature, to increase training in clinical ethics,
palliative care, and cultural diversity. Dying is a universal
human process, but we do not effectively train our future
doctors how to deal with death.
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Collecting better outcome and discharge data from the
intensive care unit, hospital, and nursing home. The state and
our academic medical centers should collect this comprehensive
data across Texas so that we can better understand the unique
circumstances in which our physicians provide end-of-life care
to their patients.
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Creating a flexible regulatory environment that facilitates
creativity and cooperation in end-of-life care services across
diverse communities. We should develop palliative care
consultation services across Texas and provide financial
support where needed - such as in rural communities or those
with high numbers of medically indigent persons.
Texans must do everything possible to prevent needless
pain.
Studies show that many terminally ill patients suffer moderate
to severe pain in the final week or two of hospitalization and most
have serious pain in the last three days of life. Surveys of those
who know they are about to die show that their top request is to
spend their final days with their families with their pain and
other symptoms under control.
Better clinical ethics, palliative care, and hospice can reduce
pain, help families, and relieve human suffering.
To reduce suffering, TMA recommends:
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Removing legal barriers to ethical, effective pain
management at the end of life. TMA opposes any move that would
endanger or prevent appropriate and aggressive pain management
practices.