The cost of health care in America is extraordinarily high, too often funding the wrong type of care. As a geriatric medicine and palliative care physician, I sit with patients and families making end-of-life decisions, weighing life-prolonging measures, optimizing quality of life, defining what matters most to them.

Recently, a 100-year-old man with severe dementia, limited mobility, hearing impairment, requiring assistance for his daily needs, was admitted to the hospital with worsening weakness. A cardiology evaluation revealed severe aortic stenosis and impaired kidney function. As I stood with my hands on the raised bedrails, he reached over and held mine, creating a moment of meaningful connection. His arms were thin and there was widespread bruising from attempts at blood draws and IV line placements. He was quiet, but when his daughter walked in, his face lit up and he called out her name. As his only child, they have lived together for the past 15 years after his spouse died. The bond between them was immediately evident. The stories of his long and fulfilling life centered around his optimism and the joy of being with his grandchildren. She described the physical and emotional toll of watching him “fade away.” We discussed his values and goals. In the context of advanced age and medical complexity, she chose to not pursue a cardiac procedure, but instead opted for hospice care at home, prioritizing his comfort, dignity, and quality of life. The psychosocial support and bereavement services provided by hospice would be beneficial for the family.

An age-friendly health systems approach aims to improve care for older adults by aligning treatment with what matters most, providing goal-concordant care that is clinically appropriate, safe, and fiscally responsible. Avoiding invasive procedures would reduce harm and, more importantly, allow him to be surrounded by the people he loved in a place that is comforting, at the end of life.

At a time when care should have eased suffering, the system instead added to it, as the care that best honored his wishes was the hardest to access. The patient’s needs exceeded what the daughter could provide, as she was in her 70s, navigating her own health challenges. The major barrier was not medical uncertainty but the financial burden of caring for him at home. This dilemma is far too common. National data suggests that home care costs average $30 per hour, which can quickly add up to thousands of dollars per week for care. This is cost-prohibitive for many families.

Had they agreed to the intervention, Medicare would have covered the substantially higher cost of a prolonged, complicated hospitalization, possibly tens of thousands of dollars, even if he died during that stay. Yet, Medicare does not cover long-term personal care services that allow patients like him to remain at home.

This is the paradox at the heart of the health care system. We readily pay for high-intensity, invasive care, but not for the support that enables comfort, dignity, and presence at the end of life. Nearly a quarter of Medicare spending occurs in the last year of life. However, much of that spending is directed toward hospital-based interventions rather than the home-based support many patients say they want.

This case highlights a systemic issue. Families across the country face the same impossible decision when choosing between financial strain and honoring a loved one’s wishes. Studies show that much of the care for older adults in the United States is provided by family members, often unpaid while bearing undue physical and emotional strain.

At the same time, well-documented cases of fraud have led to increased federal scrutiny of hospice programs, and tighter regulations in some regions, limits on the growth of new hospice providers. Efforts to address fraud must be balanced with the need to preserve access to high-quality, compassionate end-of-life care.

We might consider whether the hospice model itself could be restructured to better meet the realities families face. Hospice provides interdisciplinary medical, emotional, and spiritual support, but it does not routinely cover the hands-on care many patients need at home. Even modest extensions, such as limited personal care support or expanded trained volunteer services, could reduce caregiver burden and make the difference between dying at home and returning to the hospital.

His daughter was in anguish, overwhelmed with guilt and grief at the thought of him dying in a hospital, away from family, in a loud, unfamiliar environment. “That’s no way to die,” she remarked.

She’s right.

If we are committed to patient-centered care, our policies must reflect that by expanding home-based care, supporting family caregivers, and strengthening hospice and palliative care services, because the question is not just what care we can provide, but what kind of care we choose to value.

Denise Mohess is a geriatric medicine and palliative care physician affiliated with the Yale New Haven Health System and Bridgeport Hospital. She earned her medical degree from the University of the West Indies in Trinidad, completed her internal medicine residency at SUNY Downstate Medical Center and Abington Memorial Hospital, and went on to fellowships in geriatric medicine at the University of Pennsylvania and in hospice and palliative medicine at the Icahn School of Medicine at Mount Sinai. She holds additional certifications in bioethics, executive education, lifestyle and wellness, and grief support.

Her clinical and leadership work aims to improve the lives of patients across the care continuum, with a focus on advancing integrated geriatric and palliative care models that emphasize goal-concordant care, interdisciplinary collaboration, and interprofessional education. She is a strong advocate for recognizing caregivers as important members of the care team.

A communication expert and certified diversity professional, she is a national speaker who coaches in relationship-centered communication, leadership development, and health equity. She is engaged in several international collaborations that reflect her commitment to service and global health. She shares updates on LinkedIn.