JustCare

Tag: End of life

  • Roundup: Planning for life’s curve balls

    Roundup: Planning for life’s curve balls

    Life happens. Tomorrow, who knows what will be. At some point down the road, we are all likely to need assistance caring for ourselves. It’s wise to be prepared for life’s curve balls. Here’s a roundup of things to think about and some of the ways you might plan ahead.

    Paperwork

    Medical help

    Care

    End-0f-life choices, funerals and stuff:

  • High proportion of people flee Medicare Advantage at end of life

    High proportion of people flee Medicare Advantage at end of life

    The only question that matters when it comes to health insurance is whether it will meet your health needs when you have a costly and complex condition. Based on mounds of evidence, Medicare Advantage plans do not meet people’s costly  care needs. A new Government Accountability Office report finds that a high proportion of people flee Medicare Advantage at the end of life–they go to traditional Medicare to provide them with the care they need.

    In theory, Medicare Advantage plans are not allowed to restrict care to people with costly care needs. In practice, because they are paid a flat fee upfront to deliver care to people with Medicare and profit more when they do not spend money on care, they have every incentive to make it difficult to get costly care. And, they have the tools to do so–they choose the doctors and hospitals in their network, they design the copays and deductibles, they determine medical necessity, they decide when to delay and deny care–with virtually no oversight.

    The HHS Office of the Inspector General, the Centers for Medicare and Medicaid Services, the Government Accountability Office, and independent health researchers from around the country have all found massive problems with Medicare Advantage when it comes to providing care and coverage to people with serious health conditions. But, to date, neither Congress nor the administration has acted to protect vulnerable older and disabled Americans enrolled in Medicare Advantage.

    This new GAO study looked at people in Medicare Advantage during their last year of life. Much like other studies of people in Medicare Advantage with costly conditions, they found that people disproportionately disenrolled from Medicare Advantage because they struggled to get the specialty care they needed. As a result, Medicare spent a lot more money than it otherwise would have providing care to them. In 2017, payments for these people in traditional Medicare were estimated to be $490 million more than the Medicare Advantage plans would have received.

    The flaw in the design of Medicare Advantage plans could not be more obvious. When you combine for-profit corporations with the upfront payments they receive to cover people’s care and no link between these payments and the care they cover, these health insurers have every incentive to avoid covering care for people with costly conditions. And, so long as they have little interest in making it easy for people with costly conditions to get high-value care, they present a huge risk to people with Medicare.

    Here’s more from Just Care:

  • Six reasons why you and your loved ones should create advance directives

    Six reasons why you and your loved ones should create advance directives

    Advance care planning is important for your peace of mind and for the people you love. You should begin care planning by creating an advance directive. An advance directive is a legal document that generally includes a living will and names a health care proxy. The living will states your wishes about your health care if you cannot speak for yourself and your health care proxy is someone you name to act on your behalf regarding your medical treatment if you are unable to speak for yourself.

    Here are six reasons why you and your loved ones should create advance directives, even if you’re in good health.

    1. An advance directive is free and easy to create. Advance directives need to be in writing, but creating one comes at no cost and is generally an easy process. Click here to learn what free resources are available and how to download a free advance directive.
    1. An advance directive helps you think about the goals you have for your health and health care. Making decisions about end-of-life care isn’t easy. Some people value prolonging of life over all else, where others prioritize relief of pain and suffering or the effects of one’s care on loved ones. Whatever you decide, planning ahead can help you consider these important issues and communicate them with your friends, family and healthcare providers in a time and place where you can think things through clearly.
    1. An advance directive helps you prepare for unexpected medical situations. Many people think that they do not need to plan for their care until they reach the later stages of life. However, end-of-life situations can happen to anyone. Creating an advance directive ensures you are prepared for any medical situation that may come your way.
    1. An advance directive comforts your family and loved ones. Caregiving is hard. It’s stressful to make an end-of-life decision for someone you love if you don’t know their wishes. And, it can cause friction within a family if people’s views are not aligned. Completing an advance directive and sharing it with the people you love helps bring your family together and provides comfort to them that they are following your wishes should they need to act on your behalf. An advance directive is a legal document that doctors and hospitals must honor. The advance directive ensures the people you love can make decisions on your behalf. 
    1. An advance directive allows your doctors and other care providers to better understand you and your desires. By creating an advance directive and sharing it with your doctors, you are telling them that you are informed and involved in decisions about your care. This can reinforce a meaningful relationship between you and your doctors that, in turn, can serve as an important source of emotional support during difficult times.
    1. An advance directive speaks for you when you cannot speak for yourself. Most importantly, an advance directive makes sure you are treated the way you wish to be treated, no matter what the circumstance. (Of course, if your treatment priorities change, you can change your advance directive.) Click here for a Jon Stewart interview of Dr. Atul Gawande about the value of  sharing your end-of-life priorities with the people you love repeatedly and over time.

    After you’ve created your advance directive, be sure to give a copy to your doctor as well as to the people you love. And, if you’re not ready to share it with the people you love, at least be sure they know where you keep it.

    To learn about Medicare coverage of hospice care, click here.

    [NB: This post was originally published on May 8, 2019.]

    Here’s more from Just Care:

  • End-of-life decisions can be hard; time-limited trials can help

    End-of-life decisions can be hard; time-limited trials can help

    Paula Span reports for The New York Times on a health care initiative that can help make end-of-life decisions for individuals and their families a little easier. A “time-limited trial” offers treatment for ICU patients unable to speak for themselves to determine whether their conditions can improve. These types of trials help inform patients and their families as to whether prolonged life-sustaining treatment makes sense.

    Patients and their families often understand the risks of on-going treatment at what appears to be the end of life when the patient is in the hospital intensive care unit. Treatment can prolong pain and impair quality of life. But, they want to explore whether treatment has benefits. For example, a time-limited trial might determine whether a patient was likely to remain in a coma or continue unconscious.

    It’s unclear how often doctors let patients know that a time-limited trial is an option. But,  doctors are becoming more aware of this concept. And, a recent JAMA Internal Medicine piece describes a study of these time-limited trials in three hospitals in Los Angeles.

    Researchers trained 50 doctors on the use of time-limited trials and surveyed 200 patients, half of whom participated in time-limited trials. As a general rule, these trials occur when the medical team overseeing a patient does not believe the patient is likely to live or live a quality life that the patient would want. Yet, the patients family wants to believe that this is not the case, that their loved one’s condition will improve.

    In a time-limited trial, family members discuss their loved ones’ end-of-life desires with the medical team. The medical team, in turn, explains the interventions it can make to prolong a patient’s life, as well as the risks of these interventions. They often involve sedating the patient.

    Depending upon the treatment, the medical team and the patient’s family then decide how much time they want to give the patient on the treatment. It could be anywhere from a day to several days. The medical team establishes targets over this time to assess whether the treatment is benefiting the patient. If a patient has not improved within that time, the family and the medical team agree on a plan for stopping the treatment.

    The researchers found that time-limited trials improved medical team engagement with family members around end-of-life decisions. With time-limited trials, family members participated in decision making early on and in all but four percent of cases. It also put family members at greater ease regarding end-of-life decisions. Without the trials, family members failed to engage on end-of-life questions 40 percent of the time.

    In addition, the time-limited trials reduced patients’ stays in intensive care units. A much smaller number of them, it appears, chose interventions. But, patients in these trials died at about the same rate as patients who did not participate in these trials.

    Here’s more from Just Care:

  • Artificial intelligence machines can prompt physicians to discuss end-of-life issues

    Artificial intelligence machines can prompt physicians to discuss end-of-life issues

    StatNews reports on how artificial intelligence machines are prompting physicians to discuss end-of-life issues with their terminally ill patients. At its best, artificial intelligence leads physicians to identify patients who need to consider advance care planning.

    Physicians do not have the same ability as artificial intelligence machines to recognize when their patients are terminally ill. Physicians can be pressed for time. And, like everyone else they have a variety of biases that could keep them from recognizing which patients would benefit from advance care planning. Artificial intelligence machines, in sharp contrast, can review and process all the information in a patient’s electronic medical records objectively.

    Of course, that doesn’t mean that artificial intelligence machines are better than physicians at predicting whether a patient is terminally ill. And, the data suggests that these machines get it right less than half the time. But, as the machines improve, some believe they could be helpful.

    With the help of artificial intelligence, physicians might be prompted to have different conversations with patients than they would otherwise have. If patients are terminally ill, physicians would want to understand their goals and health care wishes. Without prompts from artificial intelligence machines, physicians might be far less likely to discuss end of life wishes with some patients.

    It can be hard for physicians to prioritize, especially when it comes to talking to their patients about end-of-life care. And timing is important. If physicians put off talking with their patients about their wishes, they might not be able to. Patients can lose their mental acumen and their ability to share their health care wishes.

    Of course, with artificial intelligence, ethical questions are at play. For example, how much should doctors be told about their patients. If artificial intelligence suggests a patient will die in three months, does the doctor need to know that? Should the patient know? What if the doctor disagrees with the artificial intelligence prediction?

    Until the accuracy of artificial intelligence machines improves–they are now no better than 45 percent accurate-most physicians will not be inclined to use them. Moreover, these machines predict likelihood of death, not who is most likely to benefit from advance care planning. But, inevitably, there will come a time when many physicians rely heavily on artificial intelligence for their treatment decisions, perhaps for the good and perhaps not.

    Here’s more from Just Care:

  • For your peace of mind and for the people you love, plan in advance for your care

    For your peace of mind and for the people you love, plan in advance for your care

    No matter how old you are, planning for your future care needs is one important gift you can give yourself and your family. Advance care planning helps ensure that your care wishes are honored if you are not able to speak for yourself.

    No one knows when they may suffer a serious illness or injury and find themselves unable to speak for themselves. That’s why advance care planning is extremely important for people of all ages. Medicare covers advance care planning as part of your Annual Wellness Visit with your primary care physician.

    If you should become seriously ill, advance care planning helps you understand and consider your care options—either curative care or hospice care. And you’ll also explore with your doctor whether you would prefer to die at home or in the hospital. You’ll ensure that the care you get is the care you want, even if you’re not able to reveal your wishes.

    Advance care planning should also include completing written advance directives—a health care proxy and living will. These legal documents help ensure your treatment wishes are honored. This advance care planning is separate from your doctor’s visit. Advance directives–a health care proxy and a living will–ensure your designated agent can speak on your behalf and honor your care wishes. Through a living will, you make clear your health care wishes should you not be able to express them. Through a health care proxy, you name someone you trust to speak on your behalf if you cannot speak for yourself.

    Only three out of ten Americans have advance directives. Many people don’t realize they need them.  And, even if you want one, it’s easy to put off completing the advance care plan.  So, if you don’t yet have a living will or health care proxy, here are three steps to take on your own, when you’re spending time with family. Ideally, you should have a living will and health care proxy before a hospital stay.

    1. Talk to your parents and kids about the kind of care you would want if something were to happen to you and you could not decide for yourself the care you need. Consider as well whether you would want hospice care, which Medicare covers.
    2. Pick someone whom you trust to make decisions for you if you can’t make them yourself, your “health care proxy.”
    3. Complete a written health care proxy and living will, and share them with the person you have chosen to make decisions on your behalf, your family and loved ones, as well as with your doctors. You might also consider giving your health care proxy or someone else you trust a power of attorney. You should consult an elder care lawyer if you can.

    For a free advance directive from Caring Connections, click here. Click here for advice from Dr. Atul Gawande about planning for end-of-life care.

    Here’s more from Just Care:

  • For-profit nursing homes more likely to deny residents hospice care at the end of life

    For-profit nursing homes more likely to deny residents hospice care at the end of life

    A new study published in the Journal of American Medical Directors Association finds that for-profit nursing homes are increasingly offering their most vulnerable residents high-cost therapy at the end of life rather than hospice care. If someone you love is terminally ill in a nursing home, you may want to speak with the nursing home about different treatment options.

    Because hospice care provides comfort at the end of life and does not involve curative treatments, nursing homes make far less money on providing hospice care to their residents than other treatments such as physical therapy. Not surprisingly, researchers found that for-profit nursing homes in particular tend to steer away from delivering hospice care. Rather, these nursing homes provide a large number of therapy services—high volume at great intensity—to their dying residents, which generates more income.

    Over the last few years, a number of studies have found that for-profit nursing homes may not be providing as good care as non-profit nursing homes. A Kaiser Family Foundation report highlighted the many issues with chain nursing homes, which people should beware of. Another study found that Medicare Advantage plans were more likely to steer their patients to for-profit chain nursing homes. Yet another study revealed that Medicare’s nursing home ratings can be misleading and that you should not assume a five-star rating means good care.

    The JAMDA researchers studied care provided to nursing home residents in New York State in the 30 days before they died. There is every reason to believe that nursing homes in other states behave similarly to those in New York. The financial incentives are identical.

    Here’s more from Just Care:

  • Are we spending too much on health care at end of life?

    Are we spending too much on health care at end of life?

    A new study in Science, by Amy Finkelstein et al., suggests that we may not be spending too much on health care at the end of life. Rather, we may be spending a lot on health care when people have costly and complex conditions. Sometimes, with that spending, we end up extending people’s lives and sometimes people end up dying. Since it’s often impossible to know whether treatment will be successful, we should not be reducing health care spending on people whom we may believe are at the end of life.

    The researchers find that because we generally do not know when someone will die, we cannot assume that end-of-life spending is wasteful. In many cases our spending on people with costly conditions saves lives.

    One in 20 people with Medicare die each year. And 25 percent of Medicare spending happens in people’s last year of life. But, Medicare spending on people who are most likely to die in a given year is less than 5 percent.

    Notably, the authors found that it is extremely hard to predict who will live and who will die each year. As it turns out, people who die within a year do not have a terribly high risk of dying when they are admitted to hospital. They are slightly less likely to die within the year. Even knowing a lot about a patient gives you only 50 -50 odds of knowing whether he or she will die. There is little ability to differentiate between the people in need of complex care who will live and the ones who will die.

    The authors suggest that we still need to understand health care quality better, as well as which health care interventions work to improve health and which do not, for people with the costliest conditions. Simply assuming that we need to stop spending as much on care at the end of life is wrong.

    Here’s more from Just Care:

  • Do you need a POLST, Physician Order for Life-Sustaining Treatment?

    Do you need a POLST, Physician Order for Life-Sustaining Treatment?

    A POLST or Physician Order for Life-Sustaining Treatment is a type of advance directive written by a physician, which complements a person’s advance directive. All adults should have an advance directive documenting their end of life wishes. Adults in the last stages of life also would benefit from a POLST.

    An advance directive includes a living will–a document that details the kinds of care people would like at the end of life–and a health care proxy–a document reflecting people’s wishes regarding who should speak for them if they cannot speak for themselves.

    A POLST puts in writing a doctor’s medical orders to ensure that patients get the treatments they want and do not get the treatments they do not want in a medical crisis, when they cannot speak for themselves.

    What is the difference between an advance directive and a POLST? All adults should have an advance directive documenting their end-of-live wishes. Adults who are relatively healthy do not need a POLST. Adults who are extremely frail or ill, with less than one year to live, should consider having a POLST. The POLST is written by physicians after speaking with their patients (or their health care proxies) about their diagnosis, prognosis, treatment options and goals of care. The POLST captures the kinds of medical care individuals would want in a medical emergency. A POLST is a medical order that can direct an emergency medical team.

    What kinds of information would be included in a POLST? A POLST reflects an individual’s treatment wishes at the end of life. If individuals want all treatments possible to try to keep them alive, the POLST would document that they should get CPR and Full Treatment. Or, it might say that a patient only wants comfort measures and limited treatment. Patients always get interventions that offer them comfort, including food and fluid by mouth as tolerated. But, they may opt not to have food artificially administered.

    A POLST might indicate that patients do not want to be resuscitated if they do not have a pulse, are not breathing and are non-responsive. But, rarely is that the case. So, a POLST might also indicate whether the patient wants to be moved from home to the hospital in an emergency or would prefer to remain at home.

    Here’s more from Just Care:

  • When to avoid preventive care services

    When to avoid preventive care services

    Medicare covers a wide array of preventive care services, which can offer tremendous benefits. But, some preventive care services may cause more harm than good for people towards the end of life. Liz Szabo reports for Kaiser Health News on when to avoid preventive care services.

    Mammograms and cervical cancer screenings: Experts say that people with terminal cancers of the lung, colon and pancreas generally should not be getting a mammogram or cervical cancer screening. Similarly, people in their late eighties and older with multiple chronic conditions usually do not need these services. The risks of harm outweigh the benefits.

    Experts further say that people with severe dementia and other chronic conditions near the end of life also do not need mammograms. Not only will a mammogram not improve their quality of life, it may lead to unnecessary surgeries.  It may also lead to painful hormonal therapies that can increase risk of stroke. Moreover, a mammogram is unlikely to identify a deadly disease. The research shows that only one woman in a thousand who gets a mammogram over a lifetime does not die because the cancer was  detected before it spread.

    Prostate cancer screenings: Experts also say that older people who already have a deadly cancer or who are at grave risk of dying within ten years are not likely to be helped by prostate screenings, PSA tests. PSA tests tend to identify tumors that are extremely slow-growing and do not need to be treated. And more than two in three prostate cancer screenings find something that does not need to be found. The follow-up biopsy causes infections in about 6 percent of men, 1 percent of whom end up in the hospital. These screenings have been deemed “low value” in men 75 and older. Research shows that men who receive surgery or radiotherapy for prostate cancer are no more likely to live ten years than men who receive active monitoring.

    Colonoscopies: Colonoscopies can lead to intestinal tears. And, people 75 and older are more likely to get a tear than younger people. Colonoscopies can also lead to dehydration and fainting in older adults.

    Skin cancer removal: People in their late eighties and older also might want to avoid removing skin cancers that are not life threatening. Caring for the skin after the cancer is removed can be problematic. And wounds may not heal. More than 25 percent of people report problems with their wounds healing.

    In sum, if you are wondering why some people should avoid these “harmless” tests, it is that the tests can lead to false positives, stress, and unnecessary invasive procedures as well as medical complications.

    Here’s more from Just Care: