Why few of us get to die peacefully at home

About three-quarters of us want to die peacefully at home. Most don't get that wish.

Fewer than a quarter die at home. Most die in hospitals and nursing homes, and a tragic one-fifth die plugged into machines in intensive care, where deaths can be so harrowing that they leave survivors traumatized.

Why don't we die the way we say we want to die? In part, because saying "Just shoot me" is not a plan.

In larger part, we die bad deaths — frightened, unprepared, stripped of family and of a sense of the sacred — because of the poorly understood role that money plays in shaping the medical choices we are given years before the end. The pathway to a good or bad death begins long before the last panicked ambulance ride to the emergency room.

Medicare and private insurance pay doctors on a piecework basis for performing procedures rather than spending time with patients. This "fast medicine" approach rewards doctors who throw tests, drugs and procedures at patients and punishes those who do slower, less invasive, higher-quality work.

To give one egregious example, a doctor who administers chemotherapy will receive 6 percent of the cost of the treatment from Medicare and almost nothing for having a long, time-consuming conversation about when to stop.

Follow the money: Some chemos cost tens of thousands a month; hospice benefit, by comparison, provides little more than $150 a day. As a result, many patients are given futile chemo, internalized cardiac defibrillators costing $35,000 and other painful, expensive, high-tech, Hail Mary surgeries and procedures close to the end of life.

Medicare spends a quarter of its $551 billion annual budget on medical treatment in the last year of life. A third of Medicare patients undergo surgery or an intensive-care-unit stay in their final year.

The most unfortunate are never given the chance to accept and face the coming of death and die in intensive care. Of those referred to hospice, a benefit available for the last six months of life, many are referred so late that they get its extraordinary, compassionate benefits for the last 18 days of their lives or less.

I discovered the terrible effects of this distorted logic in 2002, when Medicare paid $12,500 to give my stroke-blasted 80-year-old father a pacemaker to correct a slow heartbeat that gave him no health problems.

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