The health system is facing some important life and death decisions
by Cushla McKinney
It is the paradox of medicine that the better we become at treating life-threatening conditions, the greater the demands upon the health-care system become. We are continually finding ways to prolong life, from organ transplantation to chemotherapeutics, for example. Although these have the potential to benefit many people, new treatments are often expensive (the ethics of pharmaceutical costs is a subject for another day). Similarly, once-fatal illnesses are now becoming chronic conditions, requiring ongoing management. In line with this, our expectations of what ought to be provided have also risen. The refusal to provide potentially life-saving treatment provokes outrage, especially when associated with , a specific individual .
The fact that this idea -that there is some sort of price being attached to a person’s life – should instinctively be considered repellent, says a lot about the kind of society we want to live in. This is reflected in the fact that access to medical care is determined on the basis of need, rather than merit or the ability to pay.
Unfortunately, however, we cannot escape the fact that there is a limit to the amount society is able (or willing) to pay for health care. At some point one person’s treatment means that another will go without. Even if a needs-based approach to prioritising which patients and services receive funding is fairer than some other methods of allocation, considerable practical and ethical problems arise when we try to arbitrate between needs. Ought we fund a drug that will save the life of a small number of people – or should we provide hundreds of hip-replacement operations that will improve the quality of life for a large number of patients?
Does a young patient get treated before an elderly one because the former will gain more years of healthy and productive life – or, do we owe a duty to people who have spent their working lives contributing to society and, via taxes, to the health system? How much should be spent on palliative care, compared to life-extending interventions? A straight cost-benefit analysis measuring efficiency in terms of the quality and duration life gained for a particular intervention suggests that funding should be directed toward the young and healthy – but do we really want to live in a society where the elderly and terminally ill are discriminated against? On the other hand, we are facing a situation where the cost of healthcare is predicted to increase rapidly as the population ages.
According to a 2004 report the number of people over 65 is predicted to double between 2001 and 2051 and account for 63% of the total public health budget, compared to 40% in 2001/2. So too will the number in the final year of life. Counties-Manakau District Health Board (CMDHB) has estimated that the cost of caring for a person in the final year of life is between 7 and 11% higher than the annual cost of a patient not within a year of death, and a recently- published study in the recently- published study in the New Zealand Medical Journal found that that caring for the 2290 patients who died in the region during 2007/2008 year cost about $51 million. Is this an appropriate – or effective – use of health resources, and what implications does the high cost of care for patients in the final year of life have for the future healthcare budget?
Although $51 million seems like a very large figure, it is not as alarming as it seems at first glance. In fact it only accounts for 5% of the overall CMDHB budget, and was driven up by the high costs of a small group of patients. More significantly, perhaps, the highest costs were not in the oldest age groups, but among the very young (between 28 days and 9 years) and among adults aged 50 to 70 years old. Although the highest mortality rate was for those aged between 80 and 89 years old, the average cost of care dropped rapidly after the age 79.
There are a number of possible reasons for this inverse relationship between costs of end-of-life care, and the age of death. Firstly, privately-funded care was not considered, and it is possible that older patients received hospital-level care in rest homes, rather than in public hospitals. However a comprehensive survey carried out in Norway in 2006 observed similar trends, suggesting that the effect is real and probably reflects differences in treatment decisions between younger and older patients.
Although it could be argued that this reflects a de-facto rationing that becomes self-reinforcing (the closer a person is to death, the less likely they are to be treated, thus further hastening death), this fails to recognise the ethical dimension of decisions to provide or withhold treatment. It would be unethical for a doctor to provide treatment that is likely to be medically futile and carries with it the probability of side effects that will further decrease a patient’s quality of life. The older and frailer a person is, the greater the risks of aggressive intervention, and the less likely they are to succeed. Elderly patients are also more likely to have made living wills or at least thought about end-of-life issues than younger people, and may be more ready to reject treatment because they feel they (to quote the authors) “have had a fair innings.” The Norwegian research suggests that end-of-life decisions were made in 44% of all deaths, and it would be interesting to know what this figure is in New Zealand.
Cause of death also has a marked influence on the overall costs of care. Inpatient treatment accounted for 75% of the expenditure on patients in the final year of life, with the highest cost for cancer patients. Another point of note is that while the average cost of treating a patient during the final year of life was just over $22,000, 17% of the total budget was spent on 66 patients (2.7%). Without knowing the situation of each of these patients it is difficult to make any judgements, but it does raise the concern that aggressive treatment may have been provided to some people with a very poor prognosis.
This is of concern not only because such intervention is not an ‘efficient’ use of scarce funds, but also (and more importantly) because it may not be in the best interests of the patients. Intervention when a patient has a poor prognosis may prolong life for a short time, but at such a high cost in terms of quality of life that it is not worth it. Similarly, doctors need to be prepared to withdraw treatment if it is no longer effective, even if it means the patient will die.
We can now keep extremely premature babies alive, but many (if not most) will suffer serious physical and mental disability even if they survive, for example. Similarly we can extend the life of cancer patients for weeks or months with chemotherapeutic, surgical or radiological treatment, but sometimes with severe side effects. Although it is natural to want to fight for the survival of a baby or a young parent with every weapon in the medical arsenal, sometimes it is not the right thing to do.
Such decisions are very hard to doctors and families to come to, but rather than spend money on aggressive treatment in such cases, it would (arguably) be better to divert it to palliative or hospice care.
With respect to the impact of ageing on the costs of care in the last year of life, it seems factors such as changes in the causes of death (for example increased or decreased cancer rates) and end-of-life decision making are likely to have more of an effect than the change in demographics. Treasury, too, considers that the ‘distance-to-death effect’ to be a minor component to the costs of caring for an ageing population, and even if the numbers of elderly patients are within a year of death, they will only make up 1% of the population at most.
The greatest health burden is likely to be in disability-related costs, but this need not necessarily mean further rationing of services. The Treasury report refrains from predicting future healthcare costs, the authors suggest that provided disability rates decrease by 0.5% a year, the needs of an ageing population can be accommodated by increases of health expenditure of between 0.7 and 2% of GDP a year.
Changes in the way we provide services may further offset the costs of an ageing population. Talking with Kim Hill earlier this month Talking with Kim Hill earlier this month US health policy analyst Maureen Bisognano described how talking with patients about their experiences has led to changes in rehabilitation of patients undergoing hip replacement, resulting in dramatically speeded up recovery and reducing the length of hospitalisation in America. She was very enthusiastic about initiatives here that have the potential to achieve similar results here, including the just-launched Ko Awatea (a collaboration between a variety of teaching and health institutions to carry out training and research aimed at improve health care provision) and Whanau Ora.
Although hard decisions still need to be made about how much we spend on health care, the amounts of money allocated to different health services are determined at political level. Even though the conversation is a difficult one, we need to continue to discuss both the economics and ethics of health care at a national level. Perhaps we will find out that the options are not as bad as we thought.
Footnote : 1. There are a number of ways of allocating health care (or any other scarce resource). For example – in theory, we could provide care to those that ‘deserve’ it (due to merit, or societal contribution). Thus, a long-serving philanthropist would take precedence over a solo parent, or a civic leader over a gang leader for example. The [obvious] problem with a ‘deserts-based ‘approach is that it requires making moral judgements about people. What we consider valuable can change over time, (eg the philanthropist may have made her money by asset-stripping former state companies, while the solo parent may be a wonderful parent and a great neighbour), and is the start of a slippery slope whereby some people’s lives are treated as being worth less than the lives of others.
Another approach would be to leave it to the free market (based on the ability to pay) or to individual effort (which is frequently measured in earning ability, but could also reflect whether one follows a healthy lifestyle). Although this could encourage people to take responsibility for ‘earning’ the right to healthcare (both financially and in terms of living healthy lifestyles), such distribution assumes that everybody begins on a level playing field, and it discounts both the impact of poverty on health and the disadvantage that arises from ill-health itself. Similar problems arise if we allocate everybody an equal share. Overall, allocation on the basis of need seems the fairest method, despite its imperfections.