A good death

The fact is often bandied about that 1/4 of all Medicare spending is on people in their last year of life. Some people are misled into thinking that this implies more futile and wasteful spending than it really does, because we only know that these people were in their last year of life retrospectively. Generally, doctors are not able to predict how long a person will live, and much of that spending represents appropriate efforts to give people additional years of meaningful life that just didn't work.

Nevertheless, we know that there is a lot of money spent on so-called "heroic" efforts to rescue people who have very low quality of life and/or no hope of living very long, and who do not want the treatment or would not want it if they were able to express their wishes. Furthermore, both the dying and their loved ones generally much prefer to die at home, or failing that in a nursing home, than in a hospital.

It turns out there is huge regional variation in the amount of Medicare spending in the last year of life, which is highly correlated with the percentage of people who die in hospitals. The movement to encourage people to make end-of-life plans, and sign advance directives or appoint a proxy -- a spouse of child, most likely -- empowered to make end-of-life decisions should the person become mentally incompetent -- has increased the number of people making such documents. The number would be even greater, of course, if the proposed Medicare benefit for consultation about end-of-life care had been included in the Patient Protection and Affordable Care Act. Alas, as we all know all too well, Sarah Palin's psychotic screaming about Death Panels put a stop to that.

While advance directives sound like a great idea, unfortunately there has been mixed evidence about whether doctors actually pay attention to them and whether they are effective in reducing unwanted and wasteful expenditures. LH Nicholas and colleagues sort some of this out for us in the new JAMA. The story is a little bit complicated but the main takeaway is fairly simple.

In regions where spending is generally high and more people die in hospitals, treatment limiting advance directives* do seem to make a difference. They reduce average spending by an estimated $5,585 per patient; decrease the probability of dying in a hospital from 47% to 38%; and may reduce the probability of receiving life support by a bit although this difference failed to reach the conventional p <.05 level of statistical significance. The message seems to be that in places where the culture generally promotes heroic measures, advance directives do make a difference. In other places, the norms are already consistent with less futile treatment so they have less impact.

But, the second takeaway is that a) not enough people have advance directives (just under half); and b) they still don't seem to be honored as much as they should be.

Anyway, if you haven't done it yet, please do. It's something we don't want to think about but it is a great favor to your loved ones to have everything clearly understood ahead of time. And to yourself, of course. Your primary care doctor should be able to help you with this even if Medicare won't pay for it.

*You are free, by the way, to make an advance directive calling for everything possible to be done to extend your life, even by one minute, and even if you are a vegetable. However, too few people actually did this to analyze the effect.