Running head: THE COST OF END-OF-LIFE CARE 1

The Cost of End-of-life Care

The end of life is a period marked by the presence of a progressing chronic disease
with pronounced symptoms of functional impairments and the presence of symptoms or
impairments resulting from the underlying conditions leading to death (Izumi, Nagae,
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Sakurai, & Imamura, 2012 ). Hence, end-of-life care is care provided to the patient within
this period of remaining life. From a medical perspective, palliative care is used to refer to
the range of interventions deemed appropriate for dying patients and includes hospice care
provided within the last six months of life (Batchelor, 2010). There are significant costs
associated with end-of-life care and research has identified cost containment strategies
consistent with the thrust of current health care reforms.
Costs Associated with End-of-life Care
Estimates show that 25% of the total annual health care costs in the country consist of
expenses during the final year of life (Kolodziej et al., 2011). Cancer is among the several
chronic illnesses that require intensive, long-term treatment and at end of life, it is the most
expensive. A patient on chemotherapy is estimated to incur an annual cost of approximately
$111,000 for pharmacy and medical services whereas the costs are significantly lower, at
$4,000 and less, for other chronic conditions unrelated to cancer (Kolodziej et al., 2011).
Besides hospital admissions for chemotherapy, aggressive end-of-life interventions are also
major cost drivers owing to about 20% to 60% of patient deaths taking place in intensive care
units (Helwick, 2012; Curtis et al., 2012). Studies of Medicare validate the high costs of end
of life care. An estimated 25% to 30% of benefits are used to pay for such care, mainly
through the Medicare Hospice Benefit program (Jennings & Morrissey, 2011). On the
average, individuals who utilized this program in 2009 had a length of stay of 86 days.
Therefore, palliative care of which hospice care is a subset should be subjected to an
evaluation to identify possible cost reduction strategies.
PPACA and Cost Containment
With the implementation of the Patient Protection and Accountable Care Act
(PPACA), a central issue is cost containment through national efforts geared toward quality
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improvement (Orentlicher, 2011). Quality means care provided on the basis of necessity and
efficacy ascertained using the principles of evidence-based practice. Care plans should
consist of interventions that have been proven to be highly beneficial as well as cost effective.
For instance, the law recognizes the value of engaging individuals in discussions about the
end of life and mandates that physicians initiate these discussions (Jennings & et al, 2011).
On the contrary, interventions, even traditionally routine ones, shown in research to have
minimal or no effect or may even cause harm to patients are foregone.
The Cost of Care as an Ethical Issue
Resources for health care are finite and limited. For instance, insurance plans whether
public or private define the range of health care services included in the coverage thereby
limiting what resources are available to the individual. The projected increase in
expenditures for end-of-life care brought on by an aging society is seen to constitute a
significant cost burden. Thus, cost becomes an ethical issue precisely because of the
limitations imposed to make sure that the health care system remains stable and continues to
meet a predictable level of the nations health care needs (Baily, 2011; Izumi et al., 2012).
Ignoring issues of cost threatens the availability and accessibility of care in the future.
Cost containment is therefore an ethical responsibility of nurses. It means good
stewardship of resources that balances the principles of patient autonomy and justice (Baily,
2011). It does not mean a reduction in manpower, supplies, and services, but efforts to
improve the quality and efficiency of care to create value and reduce waste. Although the
subject of heated debate, end-of-life care should not be exempt from cost containment. Futile
care or resource-intensive interventions that result in a less than 1% chance of survival for the
next two months will not significantly change the trajectory of terminal illness and is a waste
of limited resources (Curtis et al., 2012).
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Cost Containment Strategies in End-of-life Care
Studies show that when optimally structured, palliative care in conjunction with
standard cancer care enables less intensive interventions while enhancing the quality of and
prolonging the remaining life (Kolodziej et al., 2011). However, counseling at end-of-life is
necessary to help the patient and family set realistic expectations and goals regarding
treatment, as well as dispel misconceptions about the need for intensive care. In most cases,
counseling results in patients and families foregoing resource-intensive care such as
aggressive chemotherapy that do not benefit the patient (Curtis et al., 2012).
In addition, recent studies reveal that encouraging patients to engage in advance care
planning can reduce costs at the end of life. An advanced care plan reflects patient
understanding of his or her medical condition and current treatment options, preferences for
medical treatment in the future, appointment of a surrogate decision-maker, personal beliefs
and values underlying care goals, and wishes (Detering, Hancock, and Reade & Silvester,
2010). Patients and families judge death as good when there is optimum management of
symptoms and the process of dying is not prolonged. Quality of good death is also associated
with maintaining a sense of control, reduced burden on the family, and relationships that
grow stronger. Results of a randomized clinical trial include an improved quality of life,
reduction of intensive care utilization to prolong life, and fewer psychological symptoms
such as stress, depression, and anxiety in the family (Detering et al., 2010; Zhang et al.,
2009).
In a longitudinal study, the cost of care for the final week of life was found to be
35.7% lower among patients how have had end-of-life discussions with their families and a
health care professional compared to those who had none (Zhang et al., 2009). The reduced
cost amounted to $1,041 per patient. Those who engaged in such discussions and incurred
lower costs also experienced quality or good death as reported by loved ones. Patients who
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incurred higher costs and did not have end-of-life discussions were reported to have had
poorer quality deaths. As such, the aforementioned cost-reduction strategies not only relate
to direct medical costs but also intangible humanistic costs.
Finally, time-limited intensive care trials may also lower costs among patients whose
prognosis is unclear and the patient and/or the family regard aggressive care as consistent
with their goals (Curtis et al., 2012). Such trials often include criteria for making decisions to
transition into palliative care when warranted. Cost savings arise from a shorter stay in the
ICU as compared to intensive care given in futile attempts to prolong life when supportive
care is a more appropriate intervention. Again, end-of-life discussions with patients and their
families enable realistic expectations of the different treatment options and allow the making
of informed decisions. The role of nurses is to support and advocate for interdisciplinary
efforts to improve care and reduce cost.
Cost Containment Strategies of Nurses
Nurses have also taken the initiative to employ evidence-based practices to improve
the quality of end-of-life care and foster cost-effectiveness. Among patients with chronic
obstructive pulmonary disease, dyspnea often persists despite being on oxygen, steroids,
albuterol, and morphine. Costly visits to the ED and eventual hospitalization are preventable
and symptoms can be kept manageable by educating nurses and patients to employ non-
pharmacologic strategies such as distraction from music, relaxation, chest wall vibration,
breathing training, air circulation using fans, and psychotherapy (Smothers & Buck, 2012).
Meanwhile, nurses in the ICU developed the Going Home Initiative wherein patients at the
end of life are referred to hospice so that they can die at home as per their and their families
preference instead of in the hospital (Lusardi et al., 2011). Besides being cost effective,
patients, caregivers, and families reported high satisfaction rates with regard to the above
interventions.
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Further, patients with cancer continue to undergo chemotherapy on an outpatient basis
as part of palliative therapy. However, they often visit the emergency department for signs of
toxicity associated with the treatment. About 60% of such cases are noted to result in a
hospital admission and about 50% of such admissions involve chemotherapy as a palliative
treatment (Kolodziej et al., 2011). A promising intervention is enhancing patient and
caregiver education on the management of cancer-related chemotherapy toxicity at home to
reduce situations that require costly ED visits and/or hospital admissions (Curtis et al., 2012).
The support of nurses in this area of care is invaluable.
Conclusion
Improving the quality of care is necessary if organizations and health care
professionals are to provide effective and appropriate care that increases patient satisfaction
while also reducing unnecessary costs. The state of the countrys health care system, in that
resources for health care have become scarce, justifies the inclusion of cost in decision
making related to service delivery. Cost containment efforts must also address the quality of
end-of-life care to allow patients to die a good death while employing cost-effective
treatment and interventions. Advance care planning and time-limited intensive care trials are
two strategies that can reduce costs. Specifically among nurses, the use of evidence-based
non-pharmacologic interventions and establishing systems in ICUs that give patients the
option and support to die at home also contribute to quality improvement and cost
containment. Good stewardship of limited resources is warranted to sustain peoples access
to health care now and in the future.
References
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