Map of life expectancy at birth from Global Education Project.

Wednesday, February 06, 2013

A Good Death

Some of my colleagues have used Medicare claims data to track the trajectories of dying people in 2000, 2005 and 2009. The article in JAMA is a dense, hard to read recitation of numbers, basically, so let me just unpack it for you.

Superficially, it looks like good news: many fewer people died in acute care hospitals in 2009 than in 2000 (24.6% vs. 32.6%). Most people say they prefer to die at home, but failing that, a good quality nursing home is usually a much better environment than an intensive care unit. If you're shuffling off anyhow, you don't want to be hooked up to machines with weird noises and flashing lights and strangers shoving tubes into you and whatnot. And more good news: the percentage of people receiving hospice services at the time of death went up from 21.6% to 42.2%.

But, you knew there was a "but," right?

The problem is that despite what happened at the very end, more people were hospitalized, more often, during the last months of life, and many of those people who got hospice services got it for only a day or two. In other words, we're still putting dying people in the hospital, in fact more so than before, it's just that they don't stay there until the moment of death as often, they tend to get shipped out a day or two ahead. That isn't really progress.

Now it's not clear how many of these hospitalizations were "appropriate." It's hard to predict who is going to die soon and some percentage of them no doubt looked they had a chance to pull through. But most of them are people who were clearly dying, perhaps in a nursing home already, who got sent to the hospital to get an IV antibiotic infusion or emergency rehydration or some such essentially pointless treatment.

I don't mind telling you that my father could well be in this data. (It's a 20% random sample of all the deaths of people on fee-for-service Medicare in those years.) He died in 2009, in a nursing home, receiving only palliative care, and he was not hospitalized even once in his last two years of life. But it wasn't easy for my mother and I to achieve that. My mother had to write a letter (with my help) to the nursing home, stating that she did not want my father, who was severely demented, to be hospitalized or tube fed. She had to sit down with the nursing director and have a lengthy conversation in which the nursing director tried to talk her out of it.

There is, believe it or not, a financial incentive for nursing homes to hospitalize people. They get paid by Medicaid to hold the bed while the person is in the hospital, during which time they don't have to take care of the person; and then they may be able to get paid by Medicare for a period after the person returns, which is better money than Medicaid.

So until we straighten out our completely batshit crazy health care financing non-system, it's going to be very hard to fix this or any other problem.

We need universal, comprehensive, single payer national health care.


Tony Mach said...

Talking bout death:

"Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis" (via)

The advise for a heart-healthy diet – stop the sat-fat, and eat healthy PUFAs instead – might have caused disease and death? Oh my, who would have thought that? And will there be a shortage of pitch forks, once people find out? Should smart doctors invest now in pitch fork factories?

Na, people are all on anti-depressants and they couldn't put up a proper revolution even if their lives depended on it.

Tony Mach said...

Lest I forget, for those inclined to read up I recommend:
- Bill Lands

- Read up on Evolution and ask yourself if vegetable oils and high Omega-6 intake is evolutionary novel

- Look up what other food besides seed oil ("vegetable oil") is high in Omega-6 fatty acids (Hint: NONE)

- Look into "Essential fatty acid interactions" on wikipedia, especially the instructive File:EFA to Eicosanoids.svg

- Note that both n-3 and n-6 share the same enzymes for metabolism (one could even say they compete for the same enzymes)

- Ask yourself if more series 2 prostaglandins (vs. series 3) will be produced, if more n-6 fatty acids (vs. n-3) are consumed

- Ask yourself what the result of increased series 2 PGs production is

(And for good measure, I can recommend what a chap named Peter has written recently on a blog aptly named "Hyperlipid")

Tony Mach said...

Pre-emptive comment:

IT'S THE [insert country name here] PARADOX!

kathy a. said...

well, those comments are not what i expected, having nothing to do with the topic.

my mother died in 7/08, and she could be part of the cohort, too.

i can confirm that a lot of nursing homes do not really want people dying on their watch -- but some are OK with it. my grandmother (dementia + bedridden) died peacefully at her nursing home in 1996. she had actually gone to the hospital recently; she forgot she couldn't walk, and broke her leg trying to get out of bed (after 6 years of not walking).

my mom was a different story. major stroke a couple months before her death; also a broken hip, which she never could remember; and then she had bad intestinal complications. so, i agree with her having been sent to the hospital. things just deteriorated. i had POA and would have refused exploratory surgery, but she was deemed too weak anyway. i refused things like a feeding tube, and got her into hospice care in the last days. it was to the hospital's credit that they let her die there, instead of attempting a move at that point; but if she had lasted a bit longer, they would have freed the bed. mom wasn't welcome back at the old nursing home -- she was not an easy patient -- and arranging all that in her last hours would have made it all worse than it was already.

Cervantes said...

Yeah Tony, I do sometimes discuss nutrition here, I think we'd all prefer you comment on appropriate posts. If you'll do that, I'm willing to have a discussion, but if you're off topic, I'm less inclined toward it.

Kathy -- Hospice, as defined in the study, includes specialized units in hospitals. It does seem like a good idea to have them, given stories such as your mother's. And sure, hospitalization close to the time of death is sometimes appropriate or necessary. It's often futile however, so most people think the rate should go down rather than up. That's not a statement about any individual case.

kathy a. said...

my dad is yet another story. he could not get hospice care at home, because he was still actively in cancer treatment -- which is a long story that makes me angry still, because everybody knew there was no cure available, and he was dying, and he found this doctor who just kept proposing new experimental chemo treatments, which all made him very sick.

the last chemo, especially. dad had a DNR, but he developed horrible breathing distress and my stepmother panicked and took him to the hospital. and it was a dire situation, so he was intubated before anybody realized he had a DNR. so, he died in the fucking ICU instead of at home. i know he was still competent enough that it was his decision to remove the tube, knowing what would happen -- because i was there. but my dad would have been a lot better off doing hospice care at home instead of one last chemo.

kathy a. said...

with my dad, there was a conflict of imperatives. he kept getting these messages (from his upbringing; and from one of my sibs) that he had to "fight it all the way."

and that really does conflict with the concept of palliative care and a gentle exit. you can't do both at the same time.

dad died in 2003, so he could be part of the study, too.

it would have been so much better if my dad's oncologist had stopped recommending some new thing before that last chemo. dad was ready to do hospice, but for that. it is likely that his acute respiratory distress was because of that chemo; so he likely would have lived a little longer, not spent his last couple days in an ICU. he could have died at home, as he wanted, with palliative support. little oxygen; little morphine; the family gathering and laughing. i mean, we did our best under the circumstances -- right before the final coma, my sister and i said we'd sneak him out and go to jamaica, and that made him laugh -- but it pretty much sucked.

MissFifi said...

Some NJ doctors, especially oncologists who never want to lose the battle with cancer, are known to do tests on patients just a few days before they day. Why?? By not having end of life discussions in the US we are doing everyone a great disservice. Hospice is a kind alternative and should be better known. I understand the medical community for wanting to fight the good fight. I really do get it as I lost both parents to cancer and worked as a massage therapist in hospice, but doctors need to learn how to concede to the disease instead of torturing the poor patient and family.