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End-of-Life and Palliative Care

The “Summary Report on Healthcare Costs: Legal Issues, Barriers and Solutions” (Davino et al., 2009) by Mary Beth Morrissey and Bruce Jennings clearly indicates that health care costs must be brought under control and that laws and legal practices are a significant factor, both in contributing to the cost problem and in helping to solve it. In this paper we focus on the end-of-life and palliative care part of the health system, its financing and delivery systems.

Many single out this part of the health care system and attribute its rising costs to utilization that takes place in the last two years of life, or less. Indeed, medical services are often intensive and expensive for chronically and terminally ill patients; much of their care takes place in multi-site care settings, including hospitals and even intensive care units.

What are the barriers to developing end-of-life care decision making that is high quality, cost effective, and in keeping with the wishes and values of dying patients, their families and caregivers? What are possible solutions to eliminating these barriers?

Medical care near the end of life is particularly fraught with strong emotions, and resistance to understanding its complexities is strong. It is also ethically important to protect dying persons, who surely are among the most vulnerable members of society, from both inappropriate overtreatment and undertreatment.

Balancing values of efficiency and health care justice (Sulmasy, 2003) by employing a social ecology of health model in end-of-life decision making may be the biggest challenge posed by spiraling health care costs (Morrissey & Jennings, 2006). The decisions we make are decisions that affect individuals in relation to their families, caregivers, communities, the assets and resources of their communities, and the public health.

It is difficult to talk about this as a society, but talk about it we must. Our viewpoint is in keeping with a conclusion reached in a recent report from the Dartmouth Institute for Health Policy and Clinical Practice: “The nation needs a crash program to transform the management of chronic illness [i.e. treatment during the last two years of life] to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care” (Wennberg et al., 2008: 17).

We believe that our system can reduce expenditures near the end of life and improve quality of care at the same time. Improving communication in treatment decision making holds a key, as does improving access to appropriate hospice and palliative care. Changes in the law can facilitate both of these objectives.