Thursday, December 14, 2006
Rationing care at the end of life
Canada's Globe & Mail recently published a provocative editorial about health-care rationing at the end of life. The article is a call to debate, as opposed to making recommendations per se. Its context seems to assume a future crunch in health care dollars in Canada and asks how will decisions be made about what constitutes worthwhile treatments for dying patients. The article throws out questions cutting both ways--why pay for costly treatment at the end of life unlikely to extend life--but also asks by what metric does a society choose to pay for palliative-only interventions?
"What amount of benefit should be considered worthwhile? What is it worth to extend life by a few days? What if this extension in life is accompanied by a decrease in quality of life, because of the toxicity associated with treatment? What is the value of interventions that are not associated with improved survival?"
It mentions the UK's NHS's policy of not approving new treatments that cost more than ~$60,000 per quality adjust year of life gained. How does this fit with costly interventions that do not prolong life at all (intrathecal pumps)?
In the States, palliative care is frequently 'sold' to hospitals and health systems as a money saver, which is probably true currently. The problem with this is that it ties our existence to proving ongoing cost-savings which makes us vulnerable if something changes ( e.g. culture of medicine as a whole--unlikely--or our practice, or payment structures, etc.) and we are no longer so cost-attractive. This requires us to prove our worth in other ways, since policy makers won't be convinced by values-driven messages.
Thanks to Dr. Paul McIntyre for letting me know about this.
