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Semin Respir Crit Care Med 2012; 33(04): 362-369
DOI: 10.1055/s-0032-1322399
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Economics at the End of Life: Hospital and ICU Perspectives

Marya D. Zilberberg
1   EviMed Research Group, LLC, Goshen, Massachusetts
2   Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
,
Andrew F. Shorr
3   Department of Medicine, Washington Hospital Center, Washington, DC
› Author Affiliations
Further Information

Publication History

Publication Date:
08 August 2012 (online)

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Abstract

Not all feasible care is desirable care. At the end of life, aggressive interventions may not only be futile but also inappropriate because they may impair the quality of the remaining life for both the patient and the caregiver. Although it is challenging to identify patients with a poor prognosis, certain terminal conditions among the elderly, such as end-stage dementia, heart failure, and metastatic cancer, demand a more measured use of aggressive care. Frank discussions with patients and family about their desires in the context of the prognosis, as well as symptom support, can yield both economic savings and better quality of life.

Keywords

end-of-life care - futile care - intensive care unit - palliative care - health care economics
 

  • References

  • 1 Patient Protection and Affordable Care Act. http://www.ncsl.org/documents/health/ppaca-consolidated.pdf . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 2 Teno JM, Murphy D, Lynn J , et al; Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Prognosis-based futility guidelines: does anyone win? SUPPORT Investigators. J Am Geriatr Soc 1994; 42 (11) 1202-1207
    PubMedGoogle Scholar
  • 3 Esserman L, Belkora J, Lenert L. Potentially ineffective care. A new outcome to assess the limits of critical care. JAMA 1995; 274 (19) 1544-1551
    CrossrefPubMedGoogle Scholar
  • 4 Kane L. Exclusive Ethics Survey Results: Doctors Struggle with Tougher-Than-Ever Dilemmas. Medscape, November 11, 2010. http://www.medscape.com/viewarticle/731485 . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 5 Cox CE, Martinu T, Sathy SJ , et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 2009; 37 (11) 2888-2894 , quiz 2904
    CrossrefPubMedGoogle Scholar
  • 6 Sviri S, Garb Y, Stav I , et al. Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients. J Crit Care 2009; 24 (2) 293-301
    CrossrefPubMedGoogle Scholar
  • 7 American Medical Association's Council on Ethical and Judicial Affairs. Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281 (10) 937-941
    CrossrefPubMedGoogle Scholar
  • 8 Temel JS, Greer JA, Muzikansky A , et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363 (8) 733-742
    CrossrefPubMedGoogle Scholar
  • 9 Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD. Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care 2008; 46 (12) 1226-1233
    CrossrefPubMedGoogle Scholar
  • 10 Roberts RR, Frutos PW, Ciavarella GG , et al. Distribution of variable vs fixed costs of hospital care. JAMA 1999; 281 (7) 644-649
    CrossrefPubMedGoogle Scholar
  • 11 Zhao Y, Encinosa W. The Cost of End-of-Life Hospitalizations, 2007. HCUP Statistical Brief #81. November 2009, revised April 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb81.pdf . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 12 Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of intensive care services during terminal hospitalizations in England and the United States. Am J Respir Crit Care Med 2009; 180 (9) 875-880
    CrossrefPubMedGoogle Scholar
  • 13 Angus DC, Barnato AE, Linde-Zwirble WT , et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004; 32 (3) 638-643
    CrossrefPubMedGoogle Scholar
  • 14 The Dartmouth Atlas of Healthcare. http://www.dartmouthatlas.org/ . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 15 Duncan DE. What Price for Medical Miracles? High Costs At End of Life Still Part of National Health Debate. Kaiser Health News. http://www.kaiserhealthnews.org/Stories/2010/March/09/fiscal-times-end-of-life.aspx . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 16 Milbrandt EB, Kersten A, Rahim MT , et al. Growth of intensive care unit resource use and its estimated cost in Medicare. Crit Care Med 2008; 36 (9) 2504-2510
    CrossrefPubMedGoogle Scholar
  • 17 Barnato AE, McClellan MB, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res 2004; 39 (2) 363-375
    CrossrefPubMedGoogle Scholar
  • 18 Agency for Healthcare Research and Quality (AHRQ). HCUPNet. http://hcupnet.ahrq.gov/ . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 19 Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT. Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA 2010; 303 (9) 849-856
    CrossrefPubMedGoogle Scholar
  • 20 Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L ; Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigators. Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study. Crit Care 2007; 11 (1) R9
    CrossrefPubMedGoogle Scholar
  • 21 Chelluri L, Im KA, Belle SH , et al. Long-term mortality and quality of life after prolonged mechanical ventilation. Crit Care Med 2004; 32 (1) 61-69
    CrossrefPubMedGoogle Scholar
  • 22 Angus DC, Clermont G, Linde-Zwirble WT , et al; NO-06 Investigators. Healthcare costs and long-term outcomes after acute respiratory distress syndrome: a phase III trial of inhaled nitric oxide. Crit Care Med 2006; 34 (12) 2883-2890
    PubMedGoogle Scholar
  • 23 Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006; 130 (3) 869-878
    CrossrefPubMedGoogle Scholar
  • 24 Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme Jr JF. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005; 171 (4) 340-347
    CrossrefPubMedGoogle Scholar
  • 25 Mitchell SL, Teno JM, Miller SC, Mor V. A national study of the location of death for older persons with dementia. J Am Geriatr Soc 2005; 53 (2) 299-305
    CrossrefPubMedGoogle Scholar
  • 26 Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38 (1) 65-71
    CrossrefPubMedGoogle Scholar
  • 27 Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 2005; 33 (6) 1266-1271
    Google Scholar
  • 28 Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348 (16) 1546-1554
    CrossrefPubMedGoogle Scholar
  • 29 Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Facing the challenge: decreasing case fatality rates in severe sepsis despite increasing hospitalizations. Crit Care Med 2005; 33 (11) 2555-2562
    CrossrefPubMedGoogle Scholar
  • 30 Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003. Crit Care Med 2007; 35 (5) 1244-1250
    CrossrefPubMedGoogle Scholar
  • 31 Zilberberg MD, de Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery. Crit Care Med 2008; 36 (5) 1451-1455
    CrossrefPubMedGoogle Scholar
  • 32 US Census Bureau. http://www.census.gov/prod/2010pubs/p25-1138.pdf . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 33 Zilberberg MD, Tjia J. Growth in dementia-associated hospitalizations among the oldest old in the United States: implications for ethical health services planning. Arch Intern Med 2011; 171 (20) 1850-1851
    CrossrefPubMedGoogle Scholar
  • 34 Mitchell SL, Teno JM, Kiely DK , et al. The clinical course of advanced dementia. N Engl J Med 2009; 361 (16) 1529-1538
    Google Scholar
  • 35 Pisani MA, Redlich CA, McNicoll L, Ely EW, Friedkin RJ, Inouye SK. Short-term outcomes in older intensive care unit patients with dementia. Crit Care Med 2005; 33 (6) 1371-1376
    CrossrefPubMedGoogle Scholar
  • 36 Pisani MA, Murphy TE, Van Ness PH, Araujo KLB, Inouye SK. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med 2007; 167 (15) 1629-1634
    CrossrefPubMedGoogle Scholar
  • 37 Mitchell SL, Teno JM, Intrator O, Feng Z, Mor V. Decisions to forgo hospitalization in advanced dementia: a nationwide study. J Am Geriatr Soc 2007; 55 (3) 432-438
    CrossrefPubMedGoogle Scholar
  • 38 Lyketsos CG, Sheppard J-ME, Rabins PV. Dementia in elderly persons in a general hospital. Am J Psychiatry 2000; 157 (5) 704-707
    CrossrefPubMedGoogle Scholar
  • 39 Bynum JPW, Rabins PV, Weller W, Niefeld M, Anderson GF, Wu AW. The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc 2004; 52 (2) 187-194
    CrossrefPubMedGoogle Scholar
  • 40 Fillenbaum G, Heyman A, Peterson BL, Pieper CF, Weiman AL. Use and cost of hospitalization of patients with AD by stage and living arrangement: CERAD XXI. Neurology 2001; 56 (2) 201-206
    CrossrefPubMedGoogle Scholar
  • 41 Consortium to Establish a Registry for Alzheimer's Disease (CERAD). CERAD Clinical and Neuropsychology Assessment: http://cerad.mc.duke.edu/Neuropsycology.htm . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 42 Zilberberg MD, Shorr AF. Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: implications for budgets, plant and personnel planning. BMC Health Serv Res 2008; 8: 242
    CrossrefPubMedGoogle Scholar
  • 43 Hunt SA, Baker DW, Chin MH , et al; American College of Cardiology/American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001; 38 (7) 2101-2113
    CrossrefPubMedGoogle Scholar
  • 44 Curtis LH, Whellan DJ, Hammill BG , et al. Incidence and prevalence of heart failure in elderly persons, 1994-2003. Arch Intern Med 2008; 168 (4) 418-424
    CrossrefPubMedGoogle Scholar
  • 45 Curtis LH, Greiner MA, Hammill BG , et al. Early and long-term outcomes of heart failure in elderly persons, 2001-2005. Arch Intern Med 2008; 168 (22) 2481-2488
    CrossrefPubMedGoogle Scholar
  • 46 Unroe KT, Greiner MA, Hernandez AF , et al. Resource use in the last 6 months of life among medicare beneficiaries with heart failure, 2000-2007. Arch Intern Med 2011; 171 (3) 196-203
    CrossrefPubMedGoogle Scholar
  • 47 Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004; 164 (1) 83-91
    CrossrefPubMedGoogle Scholar
  • 48 Detsky AS, Stricker SC, Mulley AG, Thibault GE. Prognosis, survival, and the expenditure of hospital resources for patients in an intensive-care unit. N Engl J Med 1981; 305 (12) 667-672
    CrossrefPubMedGoogle Scholar
  • 49 Centers for Disease Control and Prevention. Lung cancer statistics. http://www.cdc.gov/cancer/lung/statistics/ . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 50 National Cancer Institute. Surveillance, epidemiology and end results. http://seer.cancer.gov/statfacts/html/all.html . Accessed December 12, 2011
    PubMedGoogle Scholar
  • 51 Wright AA, Keating NL, Balboni TA, Matulonis UA, Block SD, Prigerson HG. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. J Clin Oncol 2010; 28 (29) 4457-4464
    CrossrefPubMedGoogle Scholar
  • 52 Au DH, Udris EM, Fihn SD, McDonell MB, Curtis JR. Differences in health care utilization at the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med 2006; 166 (3) 326-331
    CrossrefPubMedGoogle Scholar
  • 53 Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A. Intensive care, survival, and expense of treating critically ill cancer patients. JAMA 1993; 269 (6) 783-786
    CrossrefPubMedGoogle Scholar
  • 54 Darmon M, Azoulay E. Critical care management of cancer patients: cause for optimism and need for objectivity. Curr Opin Oncol 2009; 21 (4) 318-326
    CrossrefPubMedGoogle Scholar
  • 55 Sharma G, Freeman J, Zhang D, Goodwin JS. Continuity of care and intensive care unit use at the end of life. Arch Intern Med 2009; 169 (1) 81-86
    CrossrefPubMedGoogle Scholar
  • 56 Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue?. J Clin Oncol 2008; 26 (23) 3860-3866
    CrossrefPubMedGoogle Scholar
  • 57 Teno JM, Gozalo P, Mitchell SL, Bynum JPW, Dosa D, Mor V. Terminal hospitalizations of nursing home residents: does facility increasing the rate of do not resuscitate orders reduce them?. J Pain Symptom Manage 2011; 41 (6) 1040-1047
    CrossrefPubMedGoogle Scholar
  • 58 Truog RD, Campbell ML, Curtis JR , et al; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008; 36 (3) 953-963
    CrossrefPubMedGoogle Scholar
  • 59 Zilberberg MD, Shorr AF. Prolonged mechanical ventilation: pushing the limits of magic in medicine?. Crit Care Med 2009; 37 (11) 2983-2985
    CrossrefPubMedGoogle Scholar
  • 60 Connors AF, Dawson NV, Desbiens NA , et al; The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995; 274 (20) 1591-1598
    CrossrefPubMedGoogle Scholar