Preparing for the last phase of life

I believe that to avoid unnecessary suffering and spending at the end of life, each of us needs to take more responsibility for how we face death. Deciding how we use the healthcare system in old age is a crucial part of facing death and may translate into worthwhile rewards.

Ironically, medical specialization and technological advances have made the process of dying more troublesome. Our modern healthcare system focuses narrowly on curing illness, but as we age, our chronic diseases become increasingly incurable. Healthcare providers too often respond by treating our symptoms because there is no cure for old age, resulting in long and costly treatments that do more to extend misery than prolong meaningful life.

The complex interplay between patients, families, guardians, and healthcare professionals compounds this. As we age, we may become incompetent and unable to make decisions about our care. Tough choices then fall to families and health professionals who may choose the safe route of doing everything possible while putting aside the immense personal, physical, familial, and financial trade-offs associated with doing everything clinically possible.

Fears of lawsuits and prosecution can tie the hands of healthcare professionals who know that “doing everything” is wasteful and harmful. Professional training can make them reliant on “curing” options and economic incentives are another force driving patients toward over-treatment.

All in all, our culture prioritizes a clinical treatment approach over a compassionate family caring approach. The results? Healthcare spending has grown at an average rate of two percent above inflation for more than three decades and a significant portion of this spending is on futile end-of-life (EOL) care. Healthcare spending accounts for almost 20 percent of our economy—almost double that of any other industrialized democracy, diminishing our ability to invest in education, children, infrastructure and the most marginalized in society.

These matters are complex and personal. Every American deserves to die with dignity and without risking bankruptcy or burdening future generations. So how do we make progress in addressing these issues?

The first step is trying to better understand—and face—our fear of death.

Another important step is envisioning our own approach to the last phase of life. We need to prepare for death as seriously as we prepare for a newborn. We must acknowledge that at some point we are old enough to die, which allows a shift in focus away from prevention, intervention, and sophisticated treatments toward a model of care that focuses on support and comfort. As a society we can avoid the default option of ineffective and expensive care with a natural death, and we can achieve this through comfort care instead of trying to cure ourselves of old age.

In upcoming blogs, I will address how individuals and families can find a better path on this journey and also work to help our policymakers understand how EOL care reform is the key to improving the healthcare system in this country.

The right prescription for EOL care

Two groups, the American Society of Consultant Pharmacists (ASCP) Deprescribing Task Force and the Choosing Wisely initiative, have joined forces. Their joint goal is to focus on the appropriate use of medications for patients at the end-of-life (EOL). Together, they have identified the importance of having conversations with patients, and have suggested a "less is more" approach to medications. They have also established a limited life expectancy of 24 months, and this time frame allows for much-needed discussions about hospice and palliative care.

Unfortunately, our health system actively discourages these thoughtful approaches (conversations & palliative care) in favor of expensive, invasive, and ultimately useless treatments. My book, The Journey's End, can help you learn more about EOL care and ways to improve it.

Decoding the biggest problem in healthcare

For health professionals, coding obligations are all consuming. This is because their compensation is in jeopardy if their services are not coded "correctly.” Studies show that healthcare professionals spend up to 50% of their time on these coding obligations. This is time that could otherwise be spent more productively, by talking with patients (or each other) about coordinating care. One major casualty of coding is the loss of quality time with patients. Arguably, coding--and its ensuing monopoly over physicians' time--is the primary cause of fragmented healthcare. The premise of the coding and billing system is that care must be accurately measured before payment is made. Unfortunately, the "care" in healthcare is not always easily or accurately measured. For example, the payment system has eviscerated everything from primary and palliative care to gerontology and mental health, because their services are difficult to quantify. Another problem is that the coding system prizes comprehensiveness and complexity. In theory, such complexity would lead to more accurate billing, but in practice it actually costs more while adding little in terms of value. In fact, there's a massive industry called Revenue Cycle Management (RCM) to deal with all of this. And to put the staggering costs of coding into perspective, RCM generated $140.4 billion in 2022 and is forecasted to grow 10.3 percent annually through 2030. For comparison, the entire US automobile market was $100.9 billion in 2022. That is $40 billion less than RCM. The concern here is clear--that medical claims processing has taken over healthcare, and disrupted the physician-patient relationship in the process. My book, The Journey’s End , explores these matters in detail and offers pragmatic solutions.