Johns Hopkins quality of care expert discusses end-of-life care, costs

Improved care begins with difficult conversations, Pronovost says

"How can we reduce end-of-life healthcare costs?"

This question was recently posed by The Wall Street Journal to 16 experts, including Peter Pronovost, a practicing anesthesiologist, critical-care physician, professor, and Johns Hopkins Medicine's senior vice president and director of the Armstrong Institute for Patient Safety and Quality.

In his response, Pronovost first acknowledged that discussions about end-of-life care are difficult but important, and he suggested that one way to cut costs would be to "consider whether palliative care and hospice are appropriate."

While hospice care seeks to alleviate pain and suffering during the final days and hours of life, palliative care is delivered alongside traditional therapies focused on eliminating disease and improving health. The combination of palliative care with typical care improves symptoms, lessens depression and anxiety, improves people's knowledge of their prognosis, helps them set appropriate goals for care, and leads to more and earlier use of hospice.

This cost of this earlier use of hospice adds up, Pronovost says. And though the goal of end-of-life care is to allow patients to die comfortably at home, this doesn't always happen. According to Pronovost, "in a study of end-of-life care for Medicare beneficiaries with cancer, 60% of Medicare patients with poor prognosis cancer were hospitalized during their last month of life. Of those, half will die in the hospital."

All of these facts and figures must be taken into account when a patient and his or her loved ones are considering end-of-life care, Pronovost says. And though the conversations will, again, be difficult, healthcare workers and patients need to have them. The sooner the better.

Says Pronovost:

Everyone should get an advance directive and appoint a durable power of attorney. These documents allow you to spell out exactly what you want and who can make medical decisions for you if you are unable to make your own. If you are seriously ill, ask your doctors about your prognosis, what life will be like in the future and how you can plan. ... According to a recent study from the Journal of Clinical Oncology, having a discussion about dying two months before death rather than one month before death allows better planning and decreases the chance of dying in the hospital from 50% to 19%.

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