Audio Slide Show Months to Live: Rethinking End-of-Life Care

December 23, 2009
Months to Live
Weighing Medical Costs of End-of-Life Care
By REED ABELSON

LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life.

“If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive.

Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Take the case of Salah Putrus, who at age 71 had a long history of heart failure.

After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government. The Senate bill calls only for studies of Medicare spending variations, so it will be up to House-Senate negotiators to resolve the matter in the final legislation.

That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

“There’s a real risk of doing harm here — real harm,” he said.

Indeed, U.C.L.A. and five other big California medical centers recently published their own research results with a striking conclusion: for heart failure patients, the hospitals that spend the most seem to save the most lives.

Testing the Thesis

Dr. Rosenthal remembers a pivotal meeting back in 2005 when he and officials at the other California hospitals met with Dartmouth researchers to discuss their findings.

“We were inspired,” Dr. Rosenthal recalled, saying he found himself agreeing with much of the criticism aimed at his institution for its aggressive approach.

The Dartmouth analysis prompted Dr. Rosenthal to seek further data. He collaborated with colleagues at U.C.L.A. and four other medical centers affiliated with the University of California system, as well as Cedars-Sinai Medical Center in Los Angeles, to design a study of why some hospitals spent so much more on dying patients than others and what they got from their efforts.

To focus their analysis, the researchers chose to look only at a single category of patients: elderly people with heart failure. The dead would be counted, as Dartmouth does, but so would the living.

What they found seemed to contradict the Dartmouth thesis. The hospital that spent the most on heart failure patients had one-third fewer deaths after six months of an initial hospital stay.

The researchers did not disclose which of the six hospitals had the best results. But for the doctors involved, the implications were clear: spending more can sometimes save lives.

“It doesn’t look like it is all waste,” said Dr. Michael K. Ong, a U.C.L.A. internist and health policy researcher who was one of the authors of the study, which was recently published in the peer-reviewed medical journal Circulation: Cardiovascular Quality and Outcomes.

Another of the authors was Dr. Michael A. Gropper, a critical care specialist at the University of California, San Francisco. The Dartmouth research has consistently portrayed his hospital as much more cost-effective in end-of-life care than U.C.L.A. But the California study gave Dr. Gropper a new perspective. “There’s no doubt that additional investments may be worthwhile,” he said.

Some other experts take a similar view.

“If you only look at the failures, you miss the benefit,” said Dr. Peter Bach, an epidemiologist at Memorial Sloan-Kettering Cancer Center in Manhattan, who has examined the medical histories of cancer patients who have died, including women with early-stage breast cancer.

“No one in their right mind would tell you not to treat these women,” he said, “even though some of them will die.”

The California researchers say they also found much less variation among the six hospitals than the Dartmouth data would indicate after they took account of significant differences among the patients the hospitals treat, including the many patients who come to U.C.L.A. for a transplant, who are, by definition, extraordinarily sick.

Over all, the California researchers found that the variation in spending among the six hospitals was significantly less than the level reported by Dartmouth. When looking at all patients hospitalized for heart failure, for example, the variation in use of resources was 27 to 44 percent lower than when they looked at only the patients who died. And that corresponded with a separate, informal analysis of Medicare spending by the Congressional Budget Office, which after adjusting for the severity of illness in patients and differences in prices among regions, found less striking variations in spending.

A report from the Medicare Payment Advisory Commission released this month also found less variation.

Dr. Rosenthal, who argues that there are also fundamental socioeconomic differences between patients in the poorer sections of Los Angeles and those in the Mayo Clinic’s small and solidly middle-class hometown of Rochester, Minn., was co-author of an op-ed article in The Los Angeles Times last summer making that case. “Health care costs are significantly higher in areas of poverty,” he wrote.

The Dartmouth researchers tend to dismiss such counterarguments, saying their conclusion — higher spending does not necessarily buy better patient outcomes — is backed by decades of research. While more spending may have yielded benefits among these six hospitals, a Dartmouth official said, hospitals generally have not shown they deliver better results when they provide more care.

Still, Dr. Elliott S. Fisher, one of the lead investigators at the Dartmouth Atlas Project, acknowledged that the California researchers’ analysis might be better able than Dartmouth’s to identify cases in which more intensive care might prove beneficial. “Sometimes more medical care is better,” he said, “but the question is when.”

He says he believes that cost-effective hospitals with good medical outcomes should be financially rewarded for their efforts and results. But he says that public policy aimed primarily at penalizing high spenders would not be the solution. “Simply reducing their prices,” he said, “won’t fix anything.”

‘Hail Mary Pass’

Just how hard it is to determine who will most benefit from expensive care is clear in the case of George Klidaras, a 49-year-old stay-at-home father of two who arrived by ambulance late at night in mid-June in need of a heart transplant.

His age might have made him a good candidate for the procedure. And so might his overall state of health. He was lucidly answering doctors’ questions when he arrived. And although he had suffered a stroke in his early 40s and had a chronic heart condition, as recently as March, Mr. Klidaras had been living a relatively normal life.

By the time Mr. Klidaras arrived at U.C.L.A., though, his heart had weakened significantly. In the preceding weeks he had already received a pacemaker and defibrillator, and his local cardiologist decided it was time to ask U.C.L.A. — a highly regarded transplant center and regional magnet for cases beyond the skill of many other hospitals — to tackle his case.

Coming to U.C.L.A. “was our Hail Mary pass,” said his wife, Andra, a postal worker.

Mr. Klidaras’s lungs were damaged from a pulmonary embolism, and he had a high white-blood-cell count — a possible sign of infection. So the first order of business was to try to determine the source of infection so he would be well enough to undergo surgery.

The flurry of activity in the intensive care unit was “overwhelming,” Ms. Klidaras recalled. Her husband saw a dizzying array of specialists, including an infectious disease doctor and a dermatologist after he developed a rash. “They gave him every antibiotic and every test,” she said.

Mr. Klidaras spent nearly five weeks in the intensive care unit, at a cost of about $10,000 a day and a total cost in the neighborhood of $300,000. And the doctors never could stabilize his condition enough for the transplant surgery.

After the doctors told Ms. Klidaras there was nothing more they could do, she told them not to resuscitate him if his heart stopped beating on its own. He died July 20.

“Until the last week, I believed he was going to make it,” Mrs. Klidaras said. “I wanted them to do everything they could to save him.”

Someone giving the strictest of reading to the Dartmouth doctrine might argue that, given the outcome, the effort devoted to the Klidaras case was a futile expenditure of time and money.

Family Struggles

For U.C.L.A.’s doctors, deciding when enough is enough is not ultimately their call. Even when they recommend against a patient’s getting another procedure or test, it may be the patients and families who cannot let go.

When doctors, patients and families have trouble agreeing when to stop medical treatment, the person typically called in is Dr. Neil S. Wenger, a practicing physician who also serves as director of the U.C.L.A. Health System Ethics Center.

“For someone to die who is in the clutches of medical care, decisions have to be made,” Dr. Wenger said. “Otherwise, you don’t get to die a reasonable death.”

The decisions may include turning off life-prolonging technologies that were put in place when there was still hope — the dialysis machine to keep the kidneys functioning, the ventilator for the lungs — but now may be the only thing keeping the patient alive.

Dr. Wenger often sees difficult family dynamics. He spent more than an hour recently counseling the relatives of a woman with a traumatic head injury who was unlikely to ever regain consciousness. When a family member suggested stopping treatment, a sibling protested, saying, “You’re killing my sister.” Such intense emotions are “extremely common,” Dr. Wenger said.

Doctors, too, often have trouble letting go.

Many acknowledge that the current payment system encourages more care, because it rewards doctors for providing additional tests and procedures — not for spending the hours sometimes necessary to guide patients and families through the long, difficult process of deciding when to stop.

“The more tubes you put in, the more you get paid,” said Dr. Patrick T. Dowling, chairman of the department of family medicine at U.C.L.A.

But the bigger challenge may be changing the “we’re not going to let you die” culture at places like U.C.L.A.

Doctors at other leading medical centers, like the one at the University of California, San Francisco, say one big difference among institutions is how doctors and nurses talk with patients and families about their choices.

“It’s a cultural thing,” said Dr. Gropper. He says the doctors and nurses at the San Francisco medical center take the time to keep talking with patients’ families and even other doctors when they seem reluctant to end treatments. “You chip away at them,” he said.

At U.C.L.A., such palliative care — treatment devised to relieve pain and make patients more comfortable, particularly at the end of life — was essentially an afterthought until just a few years ago, when an internal task force recommended that the hospital add it to its many other specialties. The hospital now has a formal unit devoted to palliative care and is building up its expertise in the field. Residents, in training to be doctors, are being taught how better to discuss these issues with patients and their families.

Some doctors are resistant, particularly those with patients who had hoped for a transplant but were removed from the list when it became clear they had no realistic chance of recovery.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”