One Question Can Stop End-of-Life Torture
Several weeks ago, Brown University's Dr. Joan Teno and her Dartmouth colleagues published a study on end-of-life care in the Journal of the American Medical Association. They looked at the records of almost 850,000 Medicare beneficiaries who died between 2000-2009 and first found good news on hospice utilization. A closer look revealed the bad news. I believe health care consumers could escape the intractable problem they discovered with one timely question.
First the good news: The percentage of our nation's elders dying under hospice care doubled in 10 years, from 21.6 percent to 42.3 percent. If patients close to death received more of the comfort-directed care of hospice and less of the highly-invasive, painful and burdensome treatment of intensive care units (ICUs), that would be very good news indeed. Needless suffering would have diminished.
But when the investigators looked at the period immediately preceding referral to hospice, they found a picture of torture and chaos. More people than ever received intense interventions, and the median number of disruptive moves from one institution to another grew from 2.1 to 3.1. ICU stays in the last month of life increased from 24 percent to 29 percent, and ventilator use also increased, from 8 percent to 9 percent. Very sick elders, just weeks from death, are still subjected to intensive and aggressive treatments. Doctors are apparently using more machines and tubes than ever, redoubling efforts to turn around a final medical crisis or forestall death.
The data indicates that when doctors finally accept the inevitable, the end is imminent. About 28 percent of patients received the comfort and care of hospice less than four days. This is a travesty. I would categorize such a last-minute, desperate transfer of a patient to hospice services as "dumping." These unfortunate patients didn't receive comfort care instead of medical tortures. They received the maximum allotment of technological interventions and then got shunted to hospice to die.
Such transfers come too late for a family to realize the enormous relief and peace of mind that comes with knowing a loved one's comfort comes first. It's too late for hospice social workers to do a thorough assessment of a patient and family's social, emotional and spiritual needs. It's barely enough time to administer and titrate medications for maximum relief of pain, anxiety, breathlessness and other distressing symptoms.
I would venture a guess that most of the patients in this study who suffered stays in an intensive care unit immediately before transfer to hospice had advance directives (61 percent of such patients do). I would further guess that most of those advance directives said the patient wanted to limit life-sustaining therapies like CPR, ventilators and other rescue treatments if they were terminally ill. (Most people who fill out advance directives decline interventions if they are dying.)
What is going on here? Why were these dying patients treated in violation of their stated preferences and the instructions on their advance directive?
Here's one reason: The advance directive says, essentially, "no life-sustaining treatment if I am dying." But left to their own habits and sensibilities, doctors define "dying" very, very narrowly. So long as some technology, futile or not, remains in medicine's bag of tricks, the patient is not "dying." In this sense, doctors are like a procrastinator putting a task off until tomorrow and believing that, technically speaking, "tomorrow" never comes.
Educators and health policy gurus have spent decades and hundreds of millions trying to turn physician behavior around. This latest study reveals not only abject failure, but lost ground as well. It's up to the people -- those approaching the end of life and those who love them -- to prevent medical habit from stealing a peaceful death.
We can change medical habit by applying a reasonable definition of "dying" for ourselves. We can save ourselves from torture by getting doctors to admit when we are likely to die within six months with or without treatment, or are unlikely to survive a hospitalization. That admission should give force to patients' preferences for the end of life, or to the advance directive if they cannot speak. But it's up to us to call the question.
I believe we must muster the courage to ask directly, "Doctor, am I dying?" "Is my mother, father, sister, spouse, or other loved one dying?" "Has the time of our careful planning arrived? Shall we avoid the trap of acting as though the inevitable will never come? Because if scientific calculations say I am likely to die during this hospitalization, I would rather die at home. If the odds are intensive care offers nothing but prolonged suffering, please refer me to hospice now."
Facing pointed questions like this, doctors will almost always tell the truth. They are very bad at starting a serious conversation about the end of life, but they can usually participate if they know a patient or family takes end-of-life planning seriously.
Sadly, we must take it upon ourselves to avoid being one of Dr. Teno's dismal statistics. If the end of a battle with cancer, chronic lung disease or dementia seems to be approaching, prepare yourself to ask the crucial question before a hospital admission. Ask it in the medical office. Ask it in the emergency room. Practice asking it before you actually have to utter the words. "Doctor, am I dying?"
For more by Barbara Coombs Lee, click here.
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