Subsidizing Invasive “Care” For the Dying

What a lot of people probably “know” about Medicare and end-of-life situations is the Big Lie told by Sarah Palin and others that the Affordable Care Act had modified Medicare to set up “death panels” aimed at forcing old people and special needs kids into the grave as a cost-saving measure.

The fact that Medicare, before and after the enactment of Obamacare, actually subsidizes invasive, humiliating, fruitless and (yes) wildly expensive care for people already at death’s doors may be hard to credit for some people. Perhaps anyone who read Palin’s infamous Facebook post on “death panels” should have to read Shannon Brownlee’s review of The Conversation: A Revolutionary Plan for End-of-Life Care, by Dr. Angelo Volandes, and Curing Medicare: One Doctor’s View of How Our Health Care System Is Failing the Elderly and How to Fix It, by Dr. Andy Lazris, in the latest issue of the Washington Monthly.

Brownlee, who is senior vice president at the Lown Institute and a lecturer at Dartmouth, skillfully weaves together accounts from Volandes and Lazris of cruel and irrational treatment regimes they’ve felt forced to administer under the current system with her own experience of her father’s death. “Go to the hospital” and “keep treating” are almost always the imperatives, regardless of what the patient or his or her family–who often have no way of understanding what’s happening to them–actually want or need.

Lying just below the surface of these… books is a set of political decisions with which the United States will be forced to grapple in coming decades. When a frail, elderly person gets sick, takes a fall, or has trouble breathing, it’s as if they have stepped onto a slippery chute leading straight into the hospital, no matter how fervently they and their families might wish to avoid invasive treatment as they age and approach death. That’s because hospital services are what our medical industrial complex has been built to offer, and delivering invasive end-of-life care is the job for which we have trained our doctors and nurses. Medicare policy, federal subsidies for hospitals, and taxpayer dollars for medical training all have helped create a technology-rich, hospital-centric system.

What we don’t do is train clinicians to talk to patients, and what we don’t have is the community-based infrastructure for delivering “high touch” care to people where they live. We don’t provide the simple services, like regular meal delivery and aides to help with housecleaning and bathing, that can help an elderly person preserve some autonomy and dignity. We don’t have enough primary care doctors practicing in the community—in part because our teaching hospitals make more money when they train more specialists—and the primary care doctors we do have are too busy to make house calls. Of course, there’s always an assisted-living facility— for those who can afford the $3,000 to $6,000 a month. For the rest of us, once we can no longer perform the simple tasks of daily living, like cooking for ourselves, or toileting, we can either move in with the kids or go to the nursing home.

My own perspective is undoubtedly colored by watching first my stepfather and then my father die slowly in ICU units during the last few years, which embroiled my family in an endless struggle to pry the truth from the armies of medical personnel treating them. When most recently my mother died suddenly, at home, we all said “it was a blessing.” Perhaps it’s time to incorporate that sentiment into our health care policies.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.