Palliative Care - Difficult Conversations, Significant Results

Terminal illness is one of the most difficult issues in medicine and health policy. Terminal illness forces us to address end of life care, death, quality of life, and the limits of modern medicine. Terminal illness is also hugely expensive. Indeed, about a quarter of all Medicare spending goes toward funding care for 5 percent of patients in their final year of life. As a result, while the mix of morality and money can be extremely difficult, it’s vital for policymakers, clinicians, and patients to come together to improve the ways in which patients with a terminal illness get treated.

Discussions about terminal illness and end-of-life care are fraught with emotions. This emotion intensifies debates, clouds judgment, and often forces us to avoid difficult conversations that could improve the way patients with a terminal illness get treated. What’s more, when questions of costs are broached in the context of terminal illness, the debates often get oversimplified down to a question of extending life on one hand versus saving money on the other.

Such has been the case in the U.S. and the U.K. In the U.S., discussions about funding palliative care and consultations about end-of-life care spawned the “death panel” debate, which festered during President Obama’s push for comprehensive health care reform. In Britain, the main drugs approval body recently denied funding for a cancer medication that extended life by weeks or months at an extraordinary cost. This sparked an almost rabid conversation about whether the government was saving money at the expense of saving life. Both these dust-ups certainly garnered headlines, but they did not lead to improvements in care for patients.

However, every now and then, an article is published that fundamentally changes the status quo. A recent piece by Jennifer Temel and colleagues, appearing in the August 18 edition of the New England Journal of Medicine, is just that kind of paper.

The article explores the impact of introducing, in addition to traditional cancer treatment, palliative care in the early stages after a patient is diagnosed with terminal lung cancer. The idea of promoting palliative care is not without controversy. While traditional medicine seeks to lengthen life, the aim of palliative care teams is to improve the quality of life for patients with a terminal diagnosis. Palliative care teams discuss with patients how they envision their last few months, inform them about and prescribe medications to lessen unpleasant symptoms, and counsel patients about their options.

Frequently, the medical community has viewed palliative care as a sign that nothing more can be done. To them, instinctively, palliative care goes against the basic goals of modern medicine and may hasten death. Discussing palliative care also forces medical staff to have difficult conversations with patients about death, terminal illness, and the limits of medicine.

To the public, palliative care can be construed as code for saving money and an attempt to deny aggressive therapy that could extend life. However, Temel’s paper suggests that this could not be further from the truth.

In a randomized control trial, Temel’s team looked at two groups of patients—151 in total—who were recently diagnosed with terminal lung cancer. Half the patients underwent the standard cancer treatment, which included access to the latest medications (or palliative care) if they wanted it. The second half received the same standard cancer treatment (including the option of the most aggressive medical treatment if they wanted it) and immediate access to palliative care.

Her team found that patients who received the early palliative care had a lower incidence of depression, less pain, and more mobility. What’s more, they also lived nearly three months longer. These results alone are enough to suggest that paying for palliative care is a good idea. However, in addition to living longer and having higher quality-of-life scores, patients who received early palliative care consumed fewer health care resources. Often these patients opted out of receiving aggressive treatment, and despite that decision, they survived longer. In short, it seems that giving patients access to early palliative care was able to increase the likelihood of people getting precisely what they often say they want out of their final months: It allowed patients to live longer, avoid suffering, reduce depression, and minimize their burden on family and others. What’s more, it saved money.

This is not an easy topic. Quite rightly, discussions about terminal illness and end-of-life care are emotionally charged. However, what Temel and colleagues’ recent paper illustrates is that if we’re willing to have difficult conversations and if we’re willing to investigate what works and what doesn’t, we’re going to get better solutions. Their paper highlights that with smart care, you can get significantly better outcomes with fewer resources.

As medicine and technology continue to evolve, and as the costs of health care continue to escalate, these kinds of debates are going to increasingly become the norm. It’s clear that we have the capacity to address these difficult issues. We can come up with solutions that improve efficiency, improve quality, and reduce costs. The real challenge is whether we can have the kind of difficult conversations and meaningful debates that allow us to implement our ideas and ultimately improve the way in which care gets delivered.


Special Contributor Zack Cooper is a research officer with the London School of Economics. His monthly column for the Health Policy Forum considers health policy from the international perspective. “Special Contributors” are regular contributors to the Health Policy Forum who pose their own opinions and policy positions in the realm of health care and health policy. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.

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