How and When to Die

End-of-life care creates complicated questions, both for families and for the broader economics of healthcare.

The term "healthcare" really describes different aspects of care. The large percentage of the US healthcare spend, about 85%, is for sick-care. Disease prevention, health maintenance, and end-of-life care bookend the equation. Yet, disease prevention and end-of-life care are opportunities to significantly reduce costs.

Dying has reappeared in the headlines, replacing the Palinesque "death panel" discussions with the recent announcement that CMS will pay for end-of-life counseling and several states moving forward assisted suicide laws.

I agree that all patients, in consultation with their families and medical professionals, should be prepared to die and make their wishes known well before the end comes. However, we need to confront some issues:

1. Many times, what patients and their families say they want as their terminal wishes, changes when they are confronted with a terminal illness.

2. Many times, particularly in complex critical care situations, care teams take care of patient teams and issues get blurred.

3. The medical issues are but one of many issues that complicate things, including financial planning, tax and estate planning, and other family dynamics.

4. Many times doctors are not aware of the patient's end-of-life instructions.

5. There are medical legal and risk management issues.

6. Often times there is no plug to pull. Rather, patients are kept alive using a myriad of technologies, none of which alone, if

withdrawn, would result in a quick, merciful death.

7. There is a difference between unnecessary, wasteful, and ineffective treatments and palliative interventions. One is justified while the other is not.

8. Reimbursement rules complicate things.

9. Depending on a patient's insurance status, there is the risk that decisions will be made based on mostly the financial impact of end-of-life decisions.

10. End-of-life scenarios are so anxiety-producing that patients and their care teams can't think straight.

Preparing to die is a necessary part of life. However, given all the other factors in play, we should not be surprised if even our best intentions don't bend the cost curve.