Wednesday, August 05, 2009

America facing death

There was a fantastic commentary in today's Chicago Tribune. In fact, a patient's husband read it this morning and was so impressed that he sent it with the hospice RN to our afternoon IDG meeting so that everyone could read it. The article "Accepting death outside the hospital" speaks in general terms at times but the author gets it.

Moore first notes that Medicare will spend $17 billion on a losing battle: preventing death. Other statistics include that 30% of Medicare's costs are spent in the last year of life, 50% of people die in the hospital, 20% of which are in ICU beds which cost 10 times as much as the daily rate for hospice. It might be easy to blame this on the government or other societal giants. But Moore notes, "we ask to be checked in. We are the problem."

"Besides, accept death? We're Americans! We're hard-wired to live fully and richly. We certainly will not go gently into that good night. Every day we cheat death. We buy automobiles with air bags on all sides, wear helmets when we bike and face infants backward in car seats. Many of us feel most alive flirting with death: We jump out of airplanes, surf with sharks and ski off-piste. We expect to be rescued from an avalanche and miracles to happen in the ER. How do we know? We've seen it on TV. That we fear death is understandable. Among human experience it's the sole unknown. But when it comes to dying, we act the same: We call 911 and leave decisions to medical professionals. We do everything medically possible to prevent death. We get hooked up. Do we fend off death? Nope."

Moore's view of hospice is a bit simplified. We've all experienced patients that do not want to sign a DNR, that do not want to discuss their wishes with their families (or vice versa), and that will never admit that they are going to die. For the sake of the article though, Moore makes her point. Hospice allows patients and families to have a say. Hospitals often do not. That again is a large generalization as there are MDs, God bless them, that are willing to have the tough conversations with families.

"Asking doesn't happen often enough, say medical experts who specialize in care for the dying. Terminally ill patients and their families need to make end-of-life choices, but they're often not asked to make them in a hospital setting. When no one asks, and no one answers, guess what? Hospitals provide aggressive, life-extending care."

I have to address one sentence in which she writes that "If you spend your last days in hospice care, your family can come and go." As I stressed to a family on the phone today, hospice does not provide custodial care. Neither will Medicare. Hospice can do continuous care or in-patient hospital stay for symptom management and respite to give the family a break. True, there are hospices that abuse continuous care, whom shall remain nameless, but when it comes down to it, families or a family hired caregiver are the ones on the frontline. There are no hospice homes in my area but it appears that most of them have guidelines about who can come to stay, either they are financially destitute or they are in the active dying stage. Someday hope my organization will have a hospice home. I think it can be a vital piece of the puzzle.

The article looks a lot at the financial cost of end of life care. And that's something we should be aware of given our health care crisis. I really think the larger issue is our attitude toward death itself. The saying goes that the only things we can be sure of in this life are death and taxes. I would say most Americans fear both. This article can hopefully be the start of a greater conversation. We need to tell our loved ones what our wishes are concerning our health, no matter how young or old we are now. We need to examine the life we live now. And if we are given a terminal diagnosis, we need to compare quality of life versus quantity of life.

1 comment:

Anonymous said...

I appreciate your blog entry. I was going to refer to it in my blog but I saw it on your blog and it has been tweeted by several hospice and palliative care people.

Please visit my blog at