It doesn't get any tougher than this: discussions revolving around end of life care, treating patients with a terminal illness with dignity, and the costs associated with intensive medical treatments are staggeringly difficult. However, every now and then, an article is published that fundamentally changes the status quo. A recent piece by Jennifer Temel and colleagues, appearing in the August 18th edition of the New England Journal of Medicine, is just that kind of paper.
The article explores the impact of introducing, in addition to traditional cancer treatment, palliative care in the early stages after a patient is diagnosed with terminal lung cancer. The authors' main finding is that when palliative care is introduced early, it can lead to significant improvements in quality of life and mood, reduce the rate of depression and even extend patients' lives. It also does all this while using fewer resources.
This just-released article centers on one of the most difficult issues in medicine and health policy: death. It addresses the underlying issue -- end of life care -- that spawned the recent 'death panel' debate which festered during President Obama's push for comprehensive health care reform. It also turns the 'death panel' debate on its head.
Take the case of Metastatic non-small-cell lung cancer. The average life expectancy for someone with this diagnosis is less than twelve months and it is the leading cause of death from cancers worldwide. This type of lung cancer also leads to a range of debilitating symptoms -- weight loss, shortness of breath, difficulty eating and coughing up blood -- all of which lead to a significant amount of suffering.
In the past, patients with this terminal diagnosis had a choice. They could undergo aggressive treatment and put up with the associated significant side effects. Or, they could be referred for palliative care -- a clinical specialty that focuses on managing of symptoms, improving psychosocial support, discussing long-term treatment options, and aiming to improve a patient's quality of life. Essentially, there was a tradeoff between aggressive treatment and palliative care.
Temel and her colleagues examined whether or not that tradeoff was a false dichotomy. In a randomized control trial, her team looked at two groups of patients -- 151 in all -- who were recently diagnosed with metastatic lung cancer. Half the patients underwent the standard cancer treatment. The second half received the standard cancer treatment and also got early and immediate access to palliative care.
The idea of promoting palliative care is not without controversy. Proponents of palliative care argue that it's essential to improving a patient's quality of life. Palliative care teams can comfortably discuss with patients how they envision their last few months, inform about and prescribe medications to dramatically lessen unpleasant symptoms and council patients about their options. Proponents of palliative care also argue that it can save resources, allowing the terminally ill to avoid high intensity, exorbitantly expensive therapies in their last stages of life. It is this last argument that has provoked a reaction.
Frequently, the medical community has viewed palliative care as a white flag -- a sign that nothing more can be done. To them, instinctively, palliative care goes against the basic goal of modern medicine -- lengthening life -- and many fear that it is associated with less aggressive care.
The issue of reducing the amount of care delivered to terminally ill patients is not an abstract question. It turns out that much of US health care spending goes towards treating patients in their final stages of life. As Atul Gawande noted in a wonderful, recent New Yorker piece, it turns out that about a quarter of all Medicare spending goes to pay for care for five per cent of patients in their final year of life, and that most of that money goes towards care of little or no clinical benefit.
There is also staggering variation across the US in how much is spent on paying for care for patients in their last two years of life. At the UCLA medical centers, for instance, patients are in the hospital an average of 31 days, with spending during that time period topping $59,000. Similarly, at NYU's Langone Medical Center, patients are in the hospital for 54 days, with costs in excess of $66,000. Contrast that with the Gundersen Clinic in Lacrosse Wisconsin -- a national leader in integrated medicine -- where patients are in the hospital for 13.5 days at an average cost of $18,000. That's suggests there's a real opportunity for savings.
In 2009, several hospitals, including Gunderson, began to lobby legislators to include provisions to reimburse hospitals for having end-of-life discussions with patients, counseling them about end-of-life care, setting up living wills and the option of palliative care. This lobbying wasn't surprising because these difficult conversations take time, and hospitals wanted to be paid for them. As a result, a clause allowing Medicare to pay for these consults was included in the bill. Outrage ensured.
Some opportunistic politicians seized on clause. They argued that it was 'downright evil', would set up 'death panels' and would 'pull the plug on grandma'. Others bristled at the idea that the federal government was tacitly encouraging end-of-life planning. The debate nearly sunk health care reform in the US.
Now, Temel's paper provides strong evidence on the impact of allowing patients to get access to palliative care soon after they're diagnosed with terminal cancer. Costs aside, the paper illustrates that palliative care can go a long way towards reducing patients' suffering in their last year of life and also allow patients to live longer. Those patients getting early palliative care had a lower incidence of depression, less pain and nausea, and more mobility. What's more they also lived nearly three months longer, on average, than patients who did not have early access to palliative care. These results alone are enough to suggest that paying for palliative care is a good idea.
The other clear finding coming out of the paper is that in addition to living longer and having higher quality of life scores, patients who received early palliative care consumed fewer health care resources. To be sure, this raises an awkward mix of morality and money, but nevertheless, it's vitally important. Those who had early palliative care were more likely to avoid aggressive chemotherapy and more frequently had advanced directives, which asked that they not be resuscitated in a crisis. In short, it seems as though giving patients access early palliative care was able to increase the likelihood of people getting precisely what they often say they want out of their final months: it allowed patients to live longer, avoid suffering, reduce depression and minimize their burden on family and others.
In the end, the fervor over 'pulling the plug on granny' led legislators to abandon the clause allowing Medicare to remunerate doctors for counseling patients on their options at the end of life. In many ways, this put to bed the 'death panel' debate. However, this result likely will not improve the quality of life for patients or increase the fiscal stability of our health system.
This is not an easy topic. As medicine and technology continue to evolve and as science allows us to live longer, these types of debates are more and more likely to become the norm. These discussions seemingly place at odds the idea of extending life with the prospect of reducing spending. Yet, as Temel's work shows, this is not necessarily the case. Some interventions -- like providing access to early palliative care -- can extend life, reduce suffering and save money.
Ultimately, we just need the courage to discuss, debate and implement these sorts of policies. However, as the health care debate shows, unless we can have a reasonable debate, unless we can tolerate discussing difficult issues, we won't be able to implement these bold ideas and in the long term, this will make things worse for patients, the health system and our fiscal security.
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