"End of Life Decisions" By Allen Weiss, MD, MBA, President and CEO

End of Life Decisions

October 1, 2009 - Among the most difficult and uncomfortable topics to discuss is, “How am I going to die?” Yet no one leaves this earth alive. Recently, as part of the national debate on health care reform, thinking about the cost of the last year of life and dying itself has moved to the forefront.

The facts about the end of life are very compelling and, for the most part, not well known:

  • 2.4 million Americans die each year with only 25% dying in their own home.
  • 70% say they would prefer to die at home.
  • The 64- to 84-year old group is anticipated to increase by 39% over the next ten years.
  • Over 80% of this older group is on Medicare.
  • 40% of dying patients choose hospice to help them through this last journey.

Medicare spends about 25% of their money on the last year of life. Some studies have shown that the final week of life being spent in the peaceful and caring environment of hospice costs about $35,000, with excellent patient and family satisfaction. The last week of life in a hospital ICU (intensive care unit), on the other hand, can cost about $350,000 with considerably less patient and family satisfaction. The goal in an ICU is to keep a person alive and pain free but ICU care can be unintentionally uncomfortable.

More than one-third of dying patients reported receiving inadequate treatment and insufficient emotional support in a hospital or nursing home, as opposed to those in a hospice environment. 70% of family members rated the care by hospice as excellent, according to a Brown University Medical School study published in the Journal of the American Medical Association.

“The majority of people facing a terminal illness, debilitating disease or simply old age, would prefer less intervention to more,” reported a recent Modern Healthcare article. The article went on to say, “About two-thirds of people die in institutions such as hospitals and nursing homes. In these settings, pain management and emotional support remain unmet needs, according to a 2004 survey of families of 1,578 deceased.”

Health care professionals realize we cannot always cure but we can always comfort. Compassionate nurses take pride on professional practices during the end of life distress. Sadly, many specialized hospital units, such as oncology, face end of life care all too frequently. Fortunately, many of the care givers have had additional training and experience to help patients and families though this life cycle event.

A special area of comfort and compassion is Pastoral Services which, in some hospitals including NCH, provide 24/7/365 availability to everyone in need—both patients and families. Additionally, during the past nine years NCH has had a training program for clergy who desire to become certified in hospital ministry. The students in this program contribute daily to end of life care as NCH administers to patients and families going through the dying process.

Giving people choices is really the goal going forward. In conversations with Dr. Dan Morris, a prominent Naples Oncologist, who made the important point that some patients are too sick and require too much hands-on care to die at home, with only an equally elderly and frail spouse as sole care-giver. These pre-terminal folks need to be hospitalized or be in a hospice home where nursing care is readily available.

Being educated, understanding the alternatives, and accepting one's own mortality are three themes that need to be developed for all Americans as we face longer life spans, rising costs and the hopefully not-too-soon inevitable event.



Dr. Allen Weiss is CEO & President of the NCH Healthcare System. He is board certified in Internal Medicine, Rheumatology and Geriatrics, and was in private practice in Naples, Florida from 1977 - 2000. Dr. Weiss is active in a variety of professional organizations and boards, and has been published in numerous medical journals, including the American Journal of Medicine and the Journal of Clinical Investigation.