We are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning. Living wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. Patient “L.J.” is my first example.
I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door. Three years ago he went into a severe depression after losing his second wife, to dementia. His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs. He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.
In recent months he has refused to be transported to an infusion center for his transfusions. Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to. His nurse has become exceptionally attached to him. As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.
Three months ago she suggested a palliative care consult. I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs? The children had demanded the palliative care consult so one was called.
The local hospice program has a new palliative care program. They bill Medicare Part B for their services. The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services.
Three months later the same nurse contacted the family and said the patient needs hospice care. I asked “why”? She told me her mother had died of cancer and hospice had been very helpful. I have no objections to working with hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point. When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.
It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care. The taxpayers’ foot the bill as the system fails from expenses it cannot meet.
Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.
