I've been deluged by two recent deaths and a number of severe illnesses among elderly (70+) friends and acquaintances and so was particularly interested in an article in JAMA that arrived today with the title "Change in End-of-Life Care for Medicare Beneficiaries." The study looked at the site where people died (home, hospital, hospice) and what type of medical care they received in the last 90 days of their lives.

An ICU may not be your first choice of where to end your days

The accompanying editorial piece, written by two Yale physicians, summarized the data well: among this large group of Medicare patients (848,303) dying in 2000, 2005, or 2009, more died in hospice care or at home in the later time frame, but ICU stays and acute care hospitalizations actually increased. In reality, hospice care, although more available and better recognized, frequently seems to be used only in the last few days of life.

This pattern of hospitalization and re-hospitalization holds true for those with other diseases and illnesses. A 2009 New England Journal of Medicine article looked at readmissions among nearly 12 million fee-for-service Medicare patients reviewing data from the 2003-2004 time frame. A startling 19.6% of those Medicare beneficiaries who had been hospitalized, then discharged, were back in the inpatient setting within thirty days and over a third (34%) within ninety days. The estimated cost to Medicare of  the total of these "bounce back" hospital stays was $17.4 billion in 2004.

A 2011 study reviewed the medical histories of nursing home patients who were hospitalized, often repeatedly. In 2012 MedPAC, the Medicare Payment Advisory Commission, recommended "reducing payments to skilled nursing facilities (SNFs) with relatively high rates of re-hospitalizations."  In 2006 the cost of early re-admissions from SNFs (within the first 30 days after hospital discharge) was $4.34 billion.

A series of Interventions to Reduce Acute Care Transfers (INTERACT II), with a goal to reduce re-admissions has been shown to be effective, cutting acute care transfers from SNFs by a sixth to a quarter. INTERACT II data from a pilot project reported in 2011 and involving 25 SNFs showed an average cost of $7,700 per nursing home and an average saving estimate to Medicare of $125,000 per 100-bed SNF.

That's the cost in terms of money, but the impact in terms of quality of life costs to patients can't be estimated easily, but is huge. So let's go back to the original JAMA article and editorial and its references.

One of the striking finding was the percentage of patients with diagnoses of dementia who actually spent some of their last days in an ICU setting. I woud have thought this figure should have fallen over the past years, but in reality, as Drs Jenq and Tinetti's editorial points out, it actually increased (18.6% in 2000 and 21.8% in 2009). If I'm demented in my last days on this earth, please don't waste precious ICU space on me!

The Yale reviewers comment that we need to set criteria for ICU admissions (as we already do for other health-care settings) makes eminent sense, Not only do we waste highly needed bed space and lots of money, potentially depriving other critically ill (and potentially recoverable) patients of the opportunity to receive the highest level of care available, in doing so we may block those, like me, who wish to die at home or in hospice, of that option...at least until the last three days.

In the article by Teno et. al., forty percent of those with COPD had an ICU stay prior to death and an equal percentage of those referred to hospice within three days of dying came there from an ICU.

At home, with your grandchild's hands on yours, may be a much better choice.

Yet, in reality, data show many of us would prefer to die at home and many of the caregivers for the terminally ill would agree.

How do we change the current picture, so that surrounded by family and perhaps even in our own bed, more of us can face the end in the relative comfort of home or with the aid of hospice?

I don't have an easy answer, but I think it's time for a national dialogue on the subject.

As things are now, I think we're avoiding coming to grips with an issue we should face up to; our health care system can't afford the costs involved and our own wishes and those of our loved ones need to be expressed in advance.

It's hard to make decisions at the last moment, so let's think about them in advance, individually, with our families and as a nation.