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The Promise and Peril of the Emphasis on Palliative Care

by | Nov 3, 2011

Jennifer Popik, J.D. Robert Powell Center for Medical Ethics

By Jennifer Popik, Robert Powell Center for Medical Ethics

With the battle over physician-assisted suicide gearing up in New England [www.nationalrighttolifenews.org/news/2011/10/why-vermont-matters-%E2%80%9Cpatient-choices-vermont%E2%80%9D-and-doctor-prescribed-death], one of the most commonly invoked arguments in favor of legalization revolves around pain.  However, in the two states where doctor-prescribed death has been affirmatively legalized, Oregon and Washington, studies have shown that not one person has used the suicide drugs because of current pain.  Instead, many of those who were prescribed the lethal drugs expressed fear of future pain.   

   Nevertheless, an argument that you will frequently hear in favor of doctor-prescribed death is that it is necessary because patients, particularly those with terminal illness, experience uncontrollable pain. Some argue that the only way to alleviate the pain is to eliminate the patient.

The better response to patients in pain is not to kill them, but to make sure that the medicine and technology currently available to control pain is used more widely, competently, and completely.  In a recent Los Angeles Times story titled, “The promise and pitfalls of palliative care,” written by staff writer Melissa Healy, Healy writes,

“Providing comfort, emotional support and coordination of specialized care used to be the job of the family physician. But few families these days have a longstanding relationship with a single physician, and even fewer doctors have the expertise or time, while trying to cure a very ill patient, to coordinate his care and tend to his physical and psychological distress. Growing quickly over the last few years, the field of palliative medicine has begun to step into this breach.”

The story describes palliative care as “explaining medical options, ensuring patient and family have a treatment plan, and standing by to manage the stressand discomforts ahead.”  Also, unlike a patient in hospice (by and large), the patient receiving palliate care may still pursue “curative therapy.”

While effective palliative care is important, and provides a clear alternative to physician-assisted suicide, there are also concerns.  As Healy points out, palliative care often lower health care costs by convincing patients to forego life-preserving treatment.  But what does this mean?

Healy noted, “In fact, a trial involving newly diagnosed lung cancer patients found that, despite choosing less aggressive treatment of their cancer, patients who got early and continuous palliative care lived about 2 1/2 months longer, on average, than those who got standard treatment (11.6 months versus 8.9 months).” This is very positive in this particular case.

However, when looking at the cost savings that might be obtained by widespread use of palliative care, Healy says, “If fully integrated into the nation’s hospitals, palliative care could lower the nation’s healthcare expenditures by reducing healthcare usage — to the tune of more than $6 billion a year, according to a 2010 estimate by the Institute of Medicine, which advises the federal government on medical matters.”

   With all of that potential savings, there comes risk. Government shortfalls, combined with huge and increasing Medicare budgets, create clear motivation to obtain cost saving, even by nudging patients to reject treatment. 

  In an Harvard Science news article, Holly Prigerson of Boston’s Dana Farber Cancer Institute, remarked, “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive . . . care like being on a ventilator in an ICU, to less costly comfort care….”[1]

   Indeed, a medical journal article of which Prigerson was lead author concluded that the mean cost of care was 35.7% less for patients who reported having end-of-life discussions, compared with patients who did not. [2] This perspective is certainly in line with President Obama’s call in Spring 2009 for “a very difficult democratic conversation” about treating “those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here.” [3]

   While palliative care is important and a clear response to those who would promote doctor prescribed death as a solution, we must be careful to  ensure that people are not nudged into rejecting treatment that might save their lives in the name of cost savings. 

[1]  http://www.empowher.com/cancer/content/end-life-talks-between-cancer-patients-and-doctors-lead-better-less-costly-care

[2] “Health Care Costs in the Last Week of Life Associations With End-of-Life Conversations,” Arch Intern Med. 2009;169(5):480-488.

[3] April 14, 2009 interview, published in the New York Times Magazine April 29, 2009.

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Categories: Assisted Suicide