The good news about modern medicine is that it is helping us live a lot longer. The bad news is ... pretty much the same thing.
Now that Americans are routinely living into their 70s, 80s and even 90s (in 1900, life expectancy was 47 years, in 2000 it was 75), most will end up sick and incapacitated for quite a few years at the end. And yet, just when it looks like death has finally come a-knocking, many of these frail folks will be rushed to the hospital and given the latest, greatest, priciest treatments.
To what end? Not so that they can return to a full and happy life, but more often so that they can return to the nursing home, or resume their dementia or slowly succumb to whatever it was that sent them to the hospital in the first place.
The reason for these interventions is not compassion. It is, for the most part, economic. "Medicare pays reasonably well for procedures and hospitalizations," says Dr. Joanne Lynn, president of Americans for Better Care of the Dying. It will, for instance, gladly pay for mammograms for patients with advanced dementia.
What it will NOT pay for, in most cases, is caregiver services — the kind that allow a sickly person to stay safe and comfortable. (One wonderful exception: Medicare pays for hospice care, even at home, but only for people near death.)
Perhaps most egregiously, Medicare does not yet pay for end-of-life education — the kind of serious time a doctor needs to sit down with a family, including the patient, to discuss what kind of life and death that patient really wants.
These discussions should be mandatory, says Dr. Frank Cervo, medical director of the Long Island State Veterans Home and an associate professor at Stony Brook University Hospital. "When I ask people to describe a good death, they say — like me — 'I'd like to go out after a good meal and a couple of beers.' But when families are making a decision in crisis mode and they haven't had this discussion, they forget what they'd want." Result? They green-light procedures out of guilt, or just plain panic. If only they'd discussed whether Dad would really want, say, a feeding tube, they might well choose to refuse one.
That, in fact, has been the case at Cervo's veterans home: Families who had hashed things out more often chose to forgo the tubes. "But in our health care system, that discussion is not reimbursable," says Cervo. "Whereas, putting in a feeding tube is."
The kind of education that Cervo is talking about is part of a movement called palliative care — a movement to make comfort and advance planning as much of a priority as intervention and cure. The result can be a little less time on Earth and a lot less suffering.
As America ages and more of us face our frail years, palliative care must get as much attention — and money — as the rescue efforts that can seem questionable, if not downright cruel.
