We Must Cut the Cost of Death to Provide Health Care for the Living : Medicine: Too many dollars go to prolong dying. Society must establish a mechanism to stop inappropriate and wildly expensive treatment.

I recently took out a breathing tube from a terminally ill patient, who then died within hours. This occurred with the blessing of the family and followed the previously expressed wishes of the patient. Death would have occurred within days, no matter what was done medically. The patient and family were spared further suffering, and thousands of dollars of hospital costs were saved.

At a time when medical costs are out of control in this country, such decisions will have to be made more often. When it is medically correct, we must consider ending inappropriate care for the terminally ill even if the physician or family is not prepared to do so.

We must decide as a society, and make it law, to spend our health-care resources on the living instead of on the dying. If we do not, then more and more services will be denied to all but the very few who can afford to pay their own health-care costs.

I am discussing here people with a terminal illness, regardless of age, in whom death will occur within days or a very few weeks. Examples include irreversible shock, terminal cancer, permanent liver failure and the end stage of AIDS.

Medical care costs in this country are expected to go from 6% of the gross national product in 1965 to 15% in the year 2000 (at a cost of $1.5 trillion that year compared to $541 billion this year). It has been shown that about 60% of Medicare costs occur in the last three months of life, with much of that expense incurred in hospitals.

The deficiencies of the health-care system in this country are well known. The 37 million Americans without health insurance overwhelm public hospitals that are understaffed and underfunded. Prenatal care for the poor is inadequate. Trauma centers are closing. Health insurance rates are rising dramatically. Curable sexually transmitted diseases are increasing, as are preventable childhood illnesses because of the failure of children to be immunized. The primary bar to solving these problems is money.

But once someone is sick enough to be hospitalized and near death, then too often “everything” is done, even when it is obvious that there is no hope of significant survival. Most health insurers recognize this paradox, but each is afraid to be the first to speak, lest it be the only one accused of trying to save money by withholding inappropriate care.

We as a society are generally recognizing that if the family and doctor agree, life-prolonging measures of no benefit to a terminally ill patient may be stopped. But that does not happen often enough, because either the family or the physician balks.

For physicians, terminating aggressive care is often seen as an admission of defeat. Perhaps more important, physicians are afraid that the family will come back later and sue if they do not do “everything.”

For family members, it is difficult to accept the death of a loved one. It is perhaps more difficult to make a decision that can be seen as speeding that death. But everyone I have talked to says that at the end of a terminal illness, he or she would not want life-prolonging measures that would offer no hope of recovery. People apparently can decide more easily for themselves than for their loved ones.

At a cost of $1,000 a day per patient or more, the collective costs for tens of thousands of hospitalized dying patients are enormous. Society needs to save at least a portion of those medical costs in order to improve health care for the living.

It will require legislation, which in turn would require each hospital to create a committee to evaluate individual terminally ill patients. The committee could be petitioned by the family or by the physician, and would consist of both physicians and consumers. It must have the authority to determine that a patient is terminally ill and to decide which medical procedures are appropriate (for relieving pain, increasing comfort and so on). Those decisions might be different for each patient.

Such committees would absolve families of the guilt of terminating intensive care. They would also protect physicians from lawsuits. And enormous amounts of health care costs would be saved..

Denial is a powerful mechanism to help us cope with life’s dangers. But we must overcome our denial of death in order to both reduce needless suffering and to provide health care to people who can truly benefit from it.