Death Panels…Really?

Researchers studied the effects of palliative care consultation on the costs of care for patients. They conclude that palliative care consultation saves about $279 per day for a patient who survives their illness and about $374 per day for a patient that ultimately dies.

During July and August, vehement debate and fearful senior citizens brought attention to provisions included in the health reform legislation currently before Congress regarding the compensation of palliative care consultation. Dubbed “death panels” by former Alaska Governor Sarah Palin, palliative care is an interdisciplinary field focusing on improving the quality of life for patients with advanced illness. Ironically, while former Governor Palin spoke against palliative care as it is provided for by the health reform bills currently under debate, she promulgated Healthcare Decisions Day on April 16, 2008 which requested every Alaskan to take time to consider their own advanced medical directives.

Researchers evaluated 8 established palliative care programs in hospitals around the nation. A retrospective analysis was based on matched cases of palliative care patients to control patients who received usual care. Patients in the study were similar in terms of age, gender, marital status, insurance status, and primary diagnosis (cancer, cardiac, pulmonary conditions, etc). Palliative care patients who lived were significantly more likely to be discharged to a nursing home (38 versus 26 percent; p<0.001) compared to usual care patients. Palliative care patients who lived were less likely to be discharged to home (56 versus 67 percent) compared to usual care patients. Among patients who died, palliative care patients were significantly less likely to go to the intensive care unit (68 versus 74 percent; p<0.001) compared to patients who received usual care.

The results of the study demonstrate that palliative care consultation is associated with reduced hospital costs for patients. For instance, ICU costs, laboratory costs, and total hospital costs are  significantly less for patients who receive palliative care consultation whether or not the patient ultimately lived or died. Among patients that died, palliative care patients expended  significantly fewer costs ($1544 per patient) for medications (many of which may have been ultimately futile such as expensive newer antibiotics). Palliative care consultation had no observable effect on radiology costs. The effects of cost savings are most notable approximately 48 hours after the palliative care consultation takes place.

While the retrospective design of this study is probably the only ethical way to uncover differences between palliative care and usual care, certain unmeasured confounders could also account for the observed findings. The authors are careful to note most of these. However, they fail to mention (or to note) religion – a key factor in a person’s beliefs about life and death and a piece of information often recorded by hospital admission and registration personnel.

Ultimately, this research suggests that palliative care consultation drives a major shift from the typical hospital mentality of “do everything” in order to extend life a long as possible. This traditional thinking often comes at the expense of a patient’s comfort and does not necessarily sway the final outcome. Palliative care can allow families and clinicians both to focus on what matters to patients – comfort and autonomy – and to recognize that death is only a natural step in the process of life.

Commentary

Death is a natural and inevitable part of life. However, as physicians we are trained to avert this immutable outcome for almost every patient by wielding every drug, procedure, or piece of technology available. Unfortunately, not every episode of illness is curable. Some families realize this, others painfully and often unrealistically prolong the lives of their loved ones. While these decisions are ultimately deeply personal, evidence at least shows us that providing advice to patients and their families can be associated with decreased utilization of the ICU and unnecessary lab tests. It can also save on total hospital costs. As a physician, discussing the end of life does not force a family to “pulling the plug on grandma.” On the contrary, it provides patients and families comfort at a time of deep emotion, spiritual revelation, and difficult decisions.