Blog - Atul Gawande Gives the Hospice Movement a Bump

Author:

Tim Hiller

July 27, 2010

Issue Areas:

Cost, Drug and Device Cost Containment, Quality & Safety

More and more, Americans are choosing to spend their final days in Hospice programs where the mission is not to extend life, but to maflasts. Instead of aggressively treating terminal diseases, Hospice programs focus on short-term objectives like diminishing pain, increasing mobility and promoting contact with family. As Atul Gawande points out in his latest piece in The New Yorker, Hospice has undeniable benefits:

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.

Compared to the track record of intensive care, Hospice seems even better:

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression.

Not only does Hospice care lead to similar or better results than aggressive treatment, but it is considerably cheaper. Consider the staggering costs of aggressive end of life treatment:

For a patient with a fatal version of [breast cancer], though, the cost curve is an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.

The subject is more than just an academic argument for me. About a month passed between when I heard my grandpa had a grapefruit sized tumor in his stomach and when I got the call that he had passed. Gramps never got surgery or chemotherapy for the tumor. Instead he spent that last month of his life at a Hospice. In his 80s and after a year or so of steadily deteriorating health he decided that he just didn’t want to spend the last days of his life sick from chemotherapy and in and out of invasive surgeries. Instead, he died comfortably, with his mental wits about him and with family. Perhaps most importantly there seemed to be closure. At his funeral, while we were all terribly sad, we were able to truly celebrate his life. Our family’s experience with hospice was so positive that, when he died, we asked that in lieu of sending flowers, people would kindly send a donation to the Hospice program where he spent the last few weeks of his life. I honestly can’t imagine feeling as good about it all had he spent the last few days of his life in and out of invasive, fruitless, and painful surgeries.