In September, the Institute of Medicine started what it hoped would become a national conversation on how well we’re prepared for dying. It published a 500-page report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” which found that neither individuals nor the health-care system are at all ready for the inevitable.
As The Post’s Jason Millman wrote at the time: “Behind all the charts and policymaking lies an uncomfortable truth about health care: We are all going to die someday, and the health-care system’s ultimate challenge is to make that certainty as painless and as peaceful as possible.”
The report, he said, “outlined comprehensive recommendations for tackling an issue that’s only getting more pressing as 10,000 baby boomers join Medicare every day.” Those recommendations included educating Americans to begin thinking about the end of life early on, along with suggestions for improving access to hospice care, training more doctors in palliative care and compensating health-care professionals for talking to patients about death.
On Tuesday, in an effort to prompt discussion, the Annals of Internal Medicine is publishing four commentaries touching on the issues raised in the report, from cancer treatment to unnecessary end-of-life treatments. Below are excerpts from each:
From “The Doctor: For Life and at the End of Life” by Philip A. Pizzo, a Stanford University professor who was co-chair of the committee that wrote the IOM report:
“How does [what we recommended] differ from what happens now? In the case of a patient with cancer, what the oncologist conveys about the potential benefits of treatment can be strikingly incongruent with what the patient understands, desires or experiences. For example, a reported 69 percent of patients with advanced lung or colorectal cancer did not understand that their condition was incurable. Although oncologists often disclose that treatment is likely noncurative, they rarely check the patient’s understanding of their communication. In addition, they present alternatives to aggressive medical therapy in fewer than one half of their encounters. Not surprisingly, although the Institute of Medicine Committee on Improving the Quality of Cancer Care recently underscored the importance of being attentive to patients’ end-of-life preferences, it noted that physicians inquire about these preferences less than one half of the time.”
From “Can the United States Buy Better Advance Care Planning?” by University of Pennsylvania professors Scott D. Halpern and Ezekiel J. Emanuel:
“Despite nearly 30 years of effort to get persons in the United States to complete advance directives, a recent trial of patients most likely to benefit from them — those with unequivocally terminal illnesses and limited life expectancies — showed that only one half had completed one. Many persons in the United States still spend time in the last six months of life (and often die) in intensive care units. Too many patients in the last days of life receive aggressive treatments, including surgery, and too few have adequate symptom control. And more than 25 percent of Medicare dollars are still allocated to care for patients in their final year of life — a proportion that has not changed in decades.”
From “Dying in America: An Opportunity to Deepen Partnerships With Patients and Families” by Debra L. Ness, president of the National Partnership for Women and Families, and Beverley H. Johnson, president of the Institute for Patient-and Family-Centered Care:
“There may be no truer test of a health-care system than how it supports persons with advanced illness or at the end of life and the loved ones who care for them. In that regard, most would agree that our health-care system struggles and often fails. For too many of these immensely vulnerable patients and their families, the trauma inherent in having a loved one become critically ill and die is compounded, rather than alleviated, by a system that is ill-prepared to provide clinically sound patient- and family-centered care. In addition to causing physical and emotional suffering, this failure contributes to soaring health-care costs that put enormous strain on families and our economy.”
“Although end-of-life issues have long been considered a societal problem that needs to be improved, the field of public health has only begun to embrace end-of-life as a health concern. Because public health’s primary focus is to prevent illness and premature death due to chronic disease and other health threats, public health professionals’ reluctance to acknowledge death or its circumstances may be understandable. However — whether we wish to admit it or not — prevention has its limits, and everyone will die eventually. Some public health professionals may also believe that end-of-life issues are a health-system problem rather than a priority to be addressed through population health efforts. Public health priorities tend to have at least one of the following characteristics: a large population burden, a major effect in terms of health and other consequences, and the potential for prevention.”