Perspectives on Healthcare - Winter 2010

February 1, 2010 Rod Hochman, MD

The goal of this series, “Perspectives in Health Care,” is to provide a point of view on various aspects of the future health care. Because end-of-life planning has become such a lightening-rod issue, I thought it would be worthwhile to make it the focus of this letter.

At some point in the health-care debate, the issue of end-of-life planning became associated with “death panels” and the idea that a group of bureaucrats will decide who lives and who doesn’t. That’s a shame because that’s not what end-of-life planning is about. In fact, it’s the opposite of that.

End-of-life planning is about you taking control and making your own decisions about how you want to live out the last few years, months and days of your life. It’s about understanding your options in advance; consulting with family and physicians (even pastors and attorneys); and making your end-of-life wishes known via advance directives and living wills.

In my view, it’s one of the most important things you can do for yourself and your loved ones, especially if you’re seriously ill or nearing the final stages of a chronic condition. It allows you and your clinical team to plan a course of care that will help you have the best possible quality of life given your medical condition, so that you and your loved ones can make the most of your time together.

Providing the best possible quality of life in the final days

Studies show that the vast majority of Americans would rather die in the comfort of their home, surrounded by loved ones, than in a hospital. But the reality is only one in four of us are given that opportunity. That’s because without an explicit understanding of a patient’s wishes, family members and physicians naturally want to do everything possible and continue the fight until the very end.

But with aggressive medical approaches, quality of life in those final days is anything but peaceful, according to a 2009 study published in the Archive of Internal Medicine. For already fragile patients, forceful measures such as emergency resuscitation or breathing ventilators can do more harm than good. What’s more, the intensive interventions don’t necessarily prolong life. In fact, they tend to end life slightly sooner, the study concluded.

The alternative is a less-intensive approach toward the end of life, one that places the focus on comfort and quality of life, if that’s what the patient chooses. This approach can be less traumatic for patients and their families, and can offer higher quality care.

As a byproduct, the less-intensive approach also happens to be less expensive. It costs more to care for a terminally ill patient in a hospital ICU than it does to care for them in the home. One study concluded that if half the adults who die of cancer each year participated in end- of-life planning, it would conservatively save about $77 million per year, with greater savings if you also look at other patient populations.

End-of-life spending varies by state, medical center

Studies show that higher spending does not equate to longer life or better quality of life. Yet the amount of Medicare dollars being spent on patients in their final two years is staggering. And researchers with the Dartmouth Atlas Project, a program at Dartmouth Medical School, have found huge variations in costs among major medical centers, even when adjusted for patient complexity and cost of living.

At Mayo Clinic, the average cost of caring for a patient in the last two years of life was $53,000. But at UCLA, it was $94,000. There was also variation in utilization: UCLA patients spent 50 more days in the hospital in the last two years of life than Mayo Clinic patients, and they had twice as many doctor’s visits.
What medical center spends the least amount on patients in the last two years of life? It’s Gunderson Lutheran in La Crosse, Wisconsin at $18,000 per patient. Why? It has one of the most-effective end-of-life counseling programs in the country. As a result, La Crosse has more residents with living wills than any place else: 96 percent of people who die there have completed an advance directive.

The lower cost in La Crosse does not mean the city is rationing or denying care. It’s simply that more of their residents have a well thought out plan for how they want to live out the rest of their lives, and often that means avoiding unwanted or excessive care.

The Palliative Care Program at Swedish

Palliative care is a medical specialty that focuses on relieving pain and managing symptoms associated with chronic conditions, as well as supporting patients and helping them prepare as they enter the final stages of their life.

Swedish began piloting a palliative care program a couple years ago, and it was so well- received by patients and very effective at helping manage complex cases, that we launched it throughout our system this year. Through the program, we’ve been able to help patients and families struggling with serious issues, such as life after a stroke and managing the complications of diabetes.

These are patients with conditions that result in unacceptable levels of pain, require frequent visits to the ER or have long, repeated hospital stays. The toll on themselves and their families is significant. That’s why it’s been so wonderful to make palliative care available to the local community. Our clinical team of physicians, social workers and even chaplains work closely with patients to help them manage these difficult issues.

Our palliative care program also offers patients and families the opportunity to begin thinking about and planning for the inevitable. It’s about talking through and understanding your options so that you can take more control and have a better chance at living out your final years the way you want to.
In other words, palliative care and end-life-planning helps ensure that a patient’s final days are lived with dignity, with as little pain as possible, and according to the patient’s wishes. To learn more about or to support our Palliative Care Program, please contact:

  • Don Theophilus, Executive Director of the Swedish Medical Center Foundation and Vice President, Development at
  • Terri Wallin, Executive Director, Swedish Visiting Nurse Services at

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