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.