Dr. Gawande, Hospice, The New Yorker and the Curious Absence of Some Inconvenient Truths: Here's the Rest of the Story

Media Golden Boy and eponymous web site star Atul Gawande has done it again with a compelling essay about death in the August 2 issue of The New Yorker. Pulling from a grab bag of instructive anecdotes, he describes America's perfect storm of imperfect dying. It's all thanks to the twin ingredients of a culture unprepared to think about mortality combined with a curiously passive health system willing to offer up any treatment, no matter how distant the odds. Steering clear of the "shoals" of blaming dysfunctional economic incentives, Dr. Gawande reminds us about some handy solutions: living wills, which introduce the living to the ars moriendi and hospice, which helps the dying meet a good end.

Unfortunately, expert essayist Dr. Gawande has skipped over some inconvenient truths. The DMCB brings you the rest of the story:

When confronted with a critically ill cancer patient (of the kind compellingly described by Dr. Gawande), popular culture would have you think the physicians can predict the likelihood of not making it out of the ICU alive and can therefore treat accordingly. The problem is that the prediction is far from perfect with an ROC, according to this study, of about 0.8 (where 1 is perfect). In other words, there are enough false positives to give physicians pause before recommending pulling the plug. By the way, for non-cancer patients, the prognostic tools are even worse.

Here's a DMCB anecdote: a patient with wildly metastatic colon cancer showed up in its clinic after a yucky ICU stay with a huge grin and said "Hey doc! Surprised to see me?"

Speaking of yucky ICU stays, common sense tells us that given a choice between a "florescent" ICU death with emotionally distant nurses versus a sunset-lit bedroom death with family, everyone would chose the latter. Suppose, however, if you asked ICU survivors about the wisdom of rolling the dice for that third option of surviving? There is research that says up to 70% would do it all over again and that, among the elderly, a majority are often satisfied with their quality of life afterwards.

Another DMCB anecdote: The DMCB accepted the transfer of an elderly patient out of the ICU onto its inpatient service. When asked about being at the business end of all those plastic tubes for all those weeks, the patient's response was "I don't remember much."

Unfortunately, neither does DMCB and its physician colleagues. Armed with state-of-the-art adult learning theories aimed at the promotion of a patently obvious societal need, the SUPPORT investigators set out to help physicians solicit patient preferences about end-of-life care. They failed. Dr. Gawande's New Yorker article makes for a great read, but it's a recycling of nostrums that's unlikely to change anything.

Which begs the question: why the interest in changing things? Could it be that the 12 months prior to death accounts for a quarter of Medicare costs? As a result, government and commercial insurers have a considerable economic incentive to steer patients with a poor prognosis away from costly health care services. The DMCB recalls another anecdote from when it was a medical director: a physician with special interest in end-of-life care asked the DMCB's managed care plan for financial support to promote living wills and surrogate decision making among our enrol lees. Among the many right reasons for doing this, he also suggested the savings from reduced claims expense would be huge and we'd make a killing. We agreed and took a pass on the creepy opportunity. Years later, this same conflict of interest was the key ingredient in the traction behind the otherwise despicable "death panels" controversy

Readers may also recall that hospitals are generally reimbursed with a fixed payment "DRG." Since the inpatient payment (with many exceptions) per patient is typically capped, patients with prolonged stays in the ICU often turn out to have costs that exceed the payment. Accordingly, steering patients toward palliative care can have a tidy return on investment. Now that is yucky.

Last but not least, it's ironic, given our national manic compulsion for "evidence-based" science to guide treatment decisions, that the research supporting the benefits of hospice is decidedly shaky. Dr. Gawande only quoted some studies that happened to support his point of view. That is the luxury of writing for The New Yorker. Unfortunately, it doesn't inform policy and one can only hope the White House will not repeat its past mistake and not pay attention.

So, what could be done? Writing in Population Health Management, Dr. Kash and colleagues point out that disease management for oncology can facilitate informed decision making about end-of-life options because it's typically external to the risk bearing sponsor and has less of a conflict of interest. The DMCB performed unpublished research that demonstrated that nurses can fill in for docs and are quite capable of doing the heavy lifting on promotion of living wills.

In addition, measurable outcomes in end-of-life cancer care are well within reach, according to Don Fetterolf, also writing in Population Health Management. They include the number of times cancer drugs are used "off label," (particularly as second or third line treatments) as well as the percent of patients that received chemotherapy within 14 days of death. These measures are not supposed to be zero, but Dr. Gawande points out that the number seems to be unreasonably high.