End-of-Life Care Issues

A Personal, Economic, Public Policy, and Public Health Crisis

Dan K. Morhaim, MD; Keshia M. Pollack, PhD, MPH


Am J Public Health. 2013;103(6):e8-e10. 

In This Article

Economic Factors

The number and proportion of those aged 65 years and older in the United States is rising steadily. In 2009, there were an estimated 39.6 million people aged 65 years or older, and by 2030, there will be about 72.1 million older persons.[14] As the baby boom generation continues to age and is impacted by chronic diseases and multiple comorbidities, and as medical technology advances, it is inevitable that health care costs will increase.

Completion of advance directives will very likely reduce health care costs. For most Americans, it is estimated that 25% or more of all the health care dollars spent in their entire lives are spent in the last months of life.[15] Money is often expended to keep people alive far past any hope of reasonable recovery, money that could be spent earlier, when the impact would be much greater in terms of quality and length of life.

According to the Congressional Research Service, more of us are dying in the hospital (58%) or nursing homes (20%) than at home (22%).[1] Expenses in institutions are always greater than those at home. One question to address is what portion of deaths in institutions would be more reasonably managed at home? The Congressional Research Service reports that family members of loved ones who died at a private home with hospice services were more likely to report "a favorable dying experience." Of patients in a hospice program, more than 70% chose to die at home.[1]

Who pays for this care? Costs for end-of-life care may be paid by private insurance, Medicare, or Medicaid, and these may be selfpaid. In fact, nearly 30% of all Medicare spending is for the last year of life, and more than 50% of that is in an acute care hospital.[15–18] In the final analysis, we, as taxpayers, employers, and individuals are all paying for this.

Ten states have advance directive registries to assist clinicians in getting appropriate access to advance directive information in an accurate and timely manner. Expanded use of electronic health records, which was included in the 2010 Patient Protection and Affordable Care Act, should facilitate this.

In the health care reform debate, the term "bending the cost curve" is used. Perhaps new systems, such as accountable care organizations, electronic health records, and "aligning incentives" will help reduce expenses without causing undue harm to patients and providers. In some instances, even standard terminology is changing.

To the extent that expensive, futile, and often painful "care" is forgone, money will be saved in the system. But it will be saved the right way: by respecting the wishes of individual patients, not by paying providers less to do more or by erecting barriers for patients to obtain needed care. For example, a number of hospital systems are now replacing the term "Do Not Resuscitate" with "Allow Natural Death."