“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” —Isaac Asimov
Of all the accomplishments achieved by Americans in the past century, one of the most dazzling has been the prolonging of the lifespan. In 1900, Americans lived 47 years on average. A healthy 70-year-old today is projected to live to the age of 84.
However, achieving such longevity requires an enormous reservoir of health-care resources devoted to those in the last year or two of their lives. End-of-life care represents 22 percent of all medical expenses, 26 percent of all Medicare expenditures and 25 percent of Medicaid expenditures, even though only 5 percent to 6 percent of Medicare enrollees die in any given year. In California, 38 percent of all medical expenditures for care during the last year of life are spent in the final month prior to death.
Patients also pay for much of that care themselves, with 20 percent of end-of-life medical expenses coming out of their own pockets. The bite can even occur before a family member becomes seriously ill. According to the Employee Benefit Research Institute, the typical working person reaching retirement age in the next decade will need to pay $158,000 in Medigap premiums to ensure proper healthcare coverage to reach the age of 80, and $223,000 to reach 85. If that person reaches age 95 — a not unreasonable near-future expectation — he or she would need $479,000.
Our American perspective on managing death is derived to some extent from the original Puritan notions of our first settlers, along with the Catholicism of our large wave of 19th century immigrants. Also, it is tempered by our steadfastly optimistic embrace of technological innovation and the pursuit of material success.
While debate on virtually every subject is permitted, discussion on end-of-life issues is particularly strained. A combination of our beliefs about the sanctity of life, our disdain of defeatism and our love of cutting-edge technology has created a culture wherein we aspire to defeat the undefeatable. Terminally ill cancer patients, for example, cling to the notion that an emerging drug therapy may cure them, or the parents or spouse of an elderly patient may elect to continue the person’s life support in the hope of a miraculous rally.
The increasing lifespan of Americans, although a remarkable achievement, has created uneasiness with how to deal with death. As a result, patient and family satisfaction with the experience of death is decidedly mixed and has driven up costs for health care at the end of life. Ironically, the vast majority of Americans say they would prefer dying in a low-tech environment such as home, preferably in the presence of their family. Sadly, most end up dying in the cold ICUs of hospitals.
Gail Wilensky, former HCFA (now CMS) administrator, sums up the disconnect between the way Americans die and the way in which they would prefer to go with a succinct irony: “We are one of those societies that regard death as an option,” she said.
Former Colorado Governor Richard Lamm was even more blunt. He observed, “We simply have invented and discovered more things to do to our aging bodies than our aging society can afford to pay for? We have created a Faustian bargain, where our aging bodies can and will divert resources that our children and grandchildren need for their own families, and that public policy needs for other important social goods.”