The Cost of Dying: End-of-Life Care

(CBS)  This story was originally published on Nov. 22, 2009. It was updated on Aug. 6, 2010.

Every medical study ever conducted has concluded that 100 percent of all Americans will eventually die. This comes as no great surprise, but the amount of money being spent at the very end of people's lives probably will.

Last year, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients' lives. That's more than the budget for the Department of Homeland Security, or the Department of Education. And it has been estimated that 20 to 30 percent of these medical expenses may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked.

Now you might think this would have been an obvious thing for Congress to address when it passed health care reform, but as we reported last November in the midst of the debate, what use to be a bipartisan issue has become a politically explosive one - a perfect example of the rising costs that threaten to bankrupt the country and how hard it is to rein them in.

Caring Connections
National Hospice and Palliative Care Organization
Full Segment: The Cost of Dying
Web Extra: Comfort and Costs
Web Extra: At Home, At Peace

Marcia Klish is either being saved by medical technology or being prevented from dying a natural death.

She is 71 years old and suffering from the complications of colon surgery and a hospital-acquired infection. She has been unconscious in the intensive care unit at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., for the better part of a week.

One of her doctors, Ira Byock, told "60 Minutes" correspondent Steve Kroft it costs up to $10,000 a day to maintain someone in the intensive care unit. Some patients remain here for weeks or even months; one has been there for six months.

"This is the way so many Americans die. Something like 18 to 20 percent of Americans spend their last days in an ICU," Byock told Kroft. "And, you know, it's extremely expensive. It's uncomfortable. Many times they have to be sedated so that they don't reflexively pull out a tube, or sometimes their hands are restrained. This is not the way most people would want to spend their last days of life. And yet this has become almost the medical last rites for people as they die."

Dr. Byock leads a team that treats and counsels patients with advanced illnesses.

He says modern medicine has become so good at keeping the terminally ill alive by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily.

"Families cannot imagine there could be anything worse than their loved one dying. But in fact, there are things worse. Most generally, it's having someone you love die badly," Byock said.

Asked what he means by "die badly," Byock told Kroft, "Dying suffering. Dying connected to machines. I mean, denial of death at some point becomes a delusion, and we start acting in ways that make no sense whatsoever. And I think that's collectively what we're doing."

A vast majority of Americans say they want to die at home, but 75 percent die in a hospital or a nursing home.

"How do so many people end up in the hospital?" Kroft asked Dr. Elliott Fisher, a researcher at the Dartmouth Institute for Health Policy.

"It's the path of least resistance," Fisher said.

The institute did a detailed analysis of Medicare records for patients in the last two years of their lives. Fisher says it is more efficient for doctors to manage patients who are seriously ill in a hospital situation, and there are other incentives that affect the cost and the care patients receive. Among them: the fact that most doctors get paid based on the number of patients that they see, and most hospitals get paid for the patients they admit.

"The way we set up the system right now, primary care physicians don't have time to spend an hour with you, see how you respond, if they wanted to adjust your medication," Fisher said. "So, the easiest thing for everybody up the stream is to admit you to the hospital. I think 30 percent of hospital stays in the United States are probably unnecessary given what our research looks like."

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[cktirumalai]

At present only 25% of Americans die at home; I do not know how many die peacefully and "naturally." All the ways in which that number can be increased could come in for discussion, so that fewer people end up lying hopelessly and incurably in a hospital at the end of life. The natural tendency is to learn all about an illness after you get it. A sharper awareness of how one continues to stay healthy into old age could pervade society. Medicine could dedicate itself to health first, to disease second. This may mean rewarding doctors for keeping us well, rather than for expensive procedures after we have become ill, even if that means paying them for seemingly "doing nothing."
Candadai Tirumalai

[Sydonia53]

betterlifeforall I as a health care professional for 30 years could not agree with you more. I have worked in various specialties in my years of nursing, and the saddest thing about our job is to watch the patients that we take care of suffer, and being a nurse taking care of these patients we suffer to because it takes an emotional toll on care givers over the years. Patients suffer because of modern medicine, many are in agonizing pain and many die alone with only a nurse holding their hand when they pass over to their next life. There are many reasons for that, mainly it is called lack of communication between the health care provider and the patient and between the patient and their family. With modern medicine we can do some miraculous things, but we can also cause people to linger for a long time. Most people will tell you they just don't want to die in pain, then when they make their decision that they've had enough here comes a family member that wants everything done. Then comes the psychiatrist to evaluate the patient to see if they are mentally capable of making that decision, then a family member is appointed their power of attorney to make medical decision for them, and the decisions made are from the heart, not sound judgement. No one wants to loose their loved one, but respect that person's wishes and leave your emotions out of it. Death is the one thing that we all have in common, and yes I have had to make that heart wrenching decision to remove life support from my father whom I dearly loved and miss every single day, but I also know that we could have kept him alive for some time before infection, malnutrition, pain and agony took him anyway. We dicussed what his end of life requests were long before he was injured, our family knew he did not want to be kept on this earth to suffer and have absolutely no quality of life. Talk to the people you love, find out what THEY want then stand beside them with all the love and respect they deserve, but most of all respect their decision.

[dontknowitall]

Is there a better way? Yes. It's called Death with Dignity and I approve of Dr. Jack Kevorkian.

[betterlifeforall]

I painfully work in health care and in an ICU unit where I see this every day when I am at work. Everyone thinks there will be a miracle and that they will walk out the same that they always have. The truth it that is does not happen. The problem is people are afraid of talking about death. It kills me to watch people and families do this to themselves because they can not face the fact that everyone dies. It got to the point that I had to leave ICU nursing for a while because it affected my life so much. Families think they are the only people that this affects, which isn't true. People need to grow up and face a fact of life. From the time we are born we start to die... It is a fact of life. Even Disney makes movies that show that to children.

[saneObserver]

I'm very painfully aware of the abilities we have to extend the dying period. It seems like we can make the heart attacks, that took people quickly, chemically impossible and I don?t really no how to navigate this new gray area of life and death. I can only say that it's always been a hardship to preserve life for the sick. However, I need to remind people that people with "hopeless" conditions get better. My dad was a Type 2 diabletic that went through years of decline. He went into heart failure, pneumonia and was on a respirator. He was in total dementia and had to be restrained to stay on the machine. We had no idea if his mind would ever come back. I couldn't stand seeing my father like that and it was a living Hell. The doctors said that it was very unlikely that he'd get off the respirator. My nightmare was that he'd become conscious and aware and have to stay on that machine. It was also that insurance would stop paying at some point and he'd run through the money I needed for my mother and disabled brother. He surprised us all and got off it and had 3 more good years. He lived at home and drove again. I also found that saying that you would never want that level of care while healthy and going to the "jumping off point" are 2 different scenarios. I would caution anybody about making a broad sweeping decision.

[daddyjim3874]

I am a 72 year old guy that loves my country. Let me make my own decision about dying with dignity. Institute euthenasia clinics where I can go at will when I decide the time is right.

[loving_daughter]

at the age of 87 my mother was diagnosed with colon cancer. The oncologist did not recommend surgery. The cardiologist did not recommend surgery due my mother's condition with congestive heart. The surgeon did recommend it and her primary care physician commented that she would do it if it were her mother. My mother initially did not want the surgery but after the primary care's comments she decided and my siblings decided to go ahead with the surgery. The found it had metastisized. She then had 12 horrible weeks in a rehab center before she could go home. My brother would show up at the rehab at all hours to make sure she was being taken care and several times had to talk to administration about her care or lack thereof. Six months after the surgery the cancer had spread to the breasts and she suffered greatly for another 8 months. The only comfort came in the last 6 weeks when a private hospice agreed to take her into their living accomodations just to give the family respite. They treated her royally and we were all grateful for the respectful end of life that she had. The hospice doctor and the primary care were in disagreement with her end of life care. In the end the family chose the advice of the hospice doctor.

I recently just saw my ex inlaws go thru the same thing with their father. Only he died a grumpy man at the age of 91. Grumpy because he wanted them to keep him alive as if he were 61 not 91. He had had 3 cardiac bypass surgeries during his life. He had suffered a stroke at 83 and recovered to about 80% but what were his chances of surviving another surgery.

I agree that there needs to be more preparedness in our society on dealing with death and the decisions that have to be made at the time. How much longer will it give the patient and will it be a quality of life that they live a normal life or will they be suffering pain physically and mentally?

Today I would have recommended that my mother not have had the surgery. The oncologist gave her 1 month with a lot of pain, instead she had 15 months with a lot of pain.

[patsy_owens]

What in the world...why not include all "special needs too...while you're at it those injured for life at a young age???

This is a bunch of crap...This is a repeat of Nazi Germany. You guys recall the Nazi poster of a disabled man in a wheelchair stating that he cost the Third Reich too much money???

Wake Up America!!!

[jenniferfry5]

patsy_owens: You are very self-absorbed and misguided. If this ever happens to someone you love, you will change your attitude.

[drangblow]

Oh please! Like many things in life, this is a matter of choice. Do what you want and let me do the same. Or can I come live with you and be taken care of when I die?

[tsigili]

Sure. The better way is to allow for patients to end their suffering, without the agony of spending weeks just dying naturally.

[gthog]

AH, but even though liberals hype checking out early at the end there will NEVER EVER be death panels (even after the true cost of obamacare becomes obviou) so anybody who says there will be is obviously kooky.

[retiredgustav]

George bush as governor of Texas signed a bill in 1999 creating death panels. http://www.commondreams.org/headlines05/0322-03.htm
I wonder if sarah palin knows about this. She better not come to Texas as she is brain dead already.