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September 18, 2014

IOM: We need to modernize America's end-of-life system

Daily Briefing

The United States should overhaul its "broken" end-of-life care system to improve patients' quality of life in their final days and to cut rising health care costs, according to a report released Wednesday by a committee of 21 experts appointed by the Institute of Medicine (IOM).

The 507-page report, titled "Dying in America," was funded by a $1.5 million anonymous donation. It was spurred by controversy over a provision for advance care planning in the Affordable Care Act that raised concerns from ACA opponents over "death panels" that would decide who would live and who would die.

Offering a counseling 'hotline' for end-of-life patients

IOM: System is ill equipped to handled end-of-life care

The report found that the U.S. health care system is ill equipped to handle end-of-life care. In addition, there is a gap between what services are available to those near the end of their lives and the care they actually want, according to the report.

Specifically, the report noted that physicians need more training on how to discuss with planning for death with their patients because many U.S. adults are unprepared. According to the report, more than 25% of U.S. adults have given little or no thought to the how they want to die.

Meanwhile, the report found that restructuring end-of-life services could lower health care spending. A 2011 analysis showed that a directive to limit treatment near an individual's time of death could save $5,585 per patient, according to Reuters. About 28% of 2011 Medicare spending—or $170 billion—was during the last six months of patients' lives, according to the Medicare Newsgroup.

"Because most people who participate in effective advance care planning choose maximizing independence and quality of life over living longer, advance care planning can potentially save health care costs associated with unnecessary and unwanted intervention," according to the report.

The ABCDEs of advance care planning

Recommendations for improving end-of-life care

"The time is now for our nation to develop a modernized end-of-life care system," says IOM Presdient Victor Dzau.

The committee provided several recommendations to improve end-of-life care in the United States including:

  • Improving palliative care training among all physicians;
  • Reimbursing providers to discuss end-of-life care and advance planning with their patients;
  • Providing comprehensive care for all patients near their end of life; and
  • Restructuring incentives to discourage the use of costly and unnecessary medical services that patients do not want.

The report encouraged the use of electronic health records.

The report also called for more discussion of end-of-life care to "help normalize the advance care planning process by starting it early, to identify a health care agent, and to obtain guidance in the event of a rare catastrophic event."

The IOM experts note that the first end-of-life conversation could occur when teenagers obtain their drivers' license and consider becoming an organ donor. Follow-up discussions could occur with social workers, counselors, or nurses at various other points of life, such as turning 18 or getting married.

According to the New York Times, many of the committee's suggestions would not require legislative action. However, some recommendations, such as changing Medicare reimbursements to encourage and cover home health services rather than hospital care, would require legislation.

Medicare may reimburse docs for end-of-life care

IOM will spend the next year holding meetings around the country to further outline its findings and recommendations.

Reaction to the report

David Walker, chair of the panel said, "The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life." He added, "The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly."

Burke Balch, director of the National Right to Life Committee's Powell Center for Medical Ethics, said, "The report’s emphasis on cost-slashing will intensify, rather than calm, the well-founded fears of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths" (Belluck, New York Times, 9/17; Simpson, Reuters, 9/17; Gold, Kaiser Health News, 9/17; Millman, "Wonkblog," Washington Post, 9/17).

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