The Elephant in the Room

It’s estimated that in 2007 Americans spent $2.26 Trillion on healthcare – that’s $7,439 per person, and 17% of the nation’s GDP (4.3 times what we spend on national defense). Way back in December 1999, no less an authority than JAMA took on “Economics, Ethics, and End-of-Life Care” in a path-breaking series of articles. In their research they found that:
-10-12% of all healthcare expenditures and
-27% of Medicare expenditures
are spent at the end of life.

While we are moving ever closer to an affirmative conclusion in the debate about whether or not healthcare is a right, we are no closer to requiring Medicare beneficiaries, let alone all Americans, to have Advance Directives and an honest discussion with their physicians as to what “end of life” could be like – hooked up to machines with tubes running in and out of every orifice, and then some. It’s not like in the movies.

An experiment in one of the VA’s nursing homes integrated a drop-down menu that required the clinician to choose between four Advance Directive orders about resuscitation in the event of a cardiopulmonary arrest, before they wrote an Admissions Order:
-full resuscitation
-do not resuscitate and do not intubate
-intubate, if necessary, but do not cardiovert, and
-cardiovert, if necessary, but do not intubate.

The second step, as reported in a February 2008 Provider article, was – within 24 hours of the resident’s admission – a requirement that the primary clinician complete a templated Advance Directive discussion note. An alert flashed every time the physician signed into the EMR until the note was completed. The result of these changes, largely enabled by the VA’s impressive EMR system, was within three months these Advance Directive discussions had risen from 4% at the beginning of the experiment to 71%. Additionally, the documentation/discussion led to a 98% concordance between clinical orders and patient preferences not to be resuscitated.

While the article did not report by percentage which of the four Advance Directive alternatives the patients selected, just the first step of having the conversation is huge. And, logically, the hospital could in good conscience – and without risk of being sued – follow the patient’s Directive; and ultimately, save the healthcare system futile-care expense. If we’ve determined that health coverage is a right for all, this sounds like an approach that CMS – and even commercial carriers – should think seriously about applying to all their beneficiaries regardless of age or health status.