A few weeks ago, I listened to a segment on NPR titled “The Town Where Everyone Talks about Death” by Chana Joffe-Walt. I’ve seen a few fellow NPR nerds discussing the piece on social media and am delighted to see it has generated quite a bit of buzz. The story focuses on La Crosse, Wisconsin, population of just over 50,000, and their unified focus on the importance of advance directives and meaningful conversations about death. An advance directive is essentially a living will, detailing instructions for medical treatment, should the person become incapacitated or unable to communicate on their own behalf. In La Crosse, 96 percent of decedents have prepared an advance directive, or document of a similar sort.[1] Compared to the national average of only 30 percent, this number is staggering.
Why is this significant? As a direct result, La Crosse spends less than any other city in the United States on end-of-life health care, typically a massive expense. More importantly, what is this indicative of? It turns out there is a serious disconnect between our misguided actions at the end of our loved ones lives and their own wishes for their final days. Most would prefer to let go gracefully. However, families often plead with doctors to pull out all the stops and do anything to give them just a little more time, no matter the consequence or cost to the system. We are far from being on the same page. Dozens of last ditch efforts and treatments add up fast, and more often than not only prolong the inevitable.
Think of yourself. Do you envision your last days being spent caged in a hospital room, hooked to towers of expensive machinery, undergoing painful tests and procedures? No one who has lived a full life would voluntarily submit to such circumstances. When death comes knocking in old age, most would prefer to be made comfortable and allowed to let go in peace. Advance directives in La Crosse offer clear evidence of this.
Additional studies reveal a similar sentiment. In a 2005 poll of 2,515 Medicare beneficiaries, only 8.4 percent said they would prefer to spend their last days in a hospital and 77.7 percent would prefer palliative drugs to relieve suffering even though they might be life-shortening.[2] The sample being composed entirely of Medicare beneficiaries is key here since it looks only at those ages 65 and over. I’m specifically interested in those who were given a fair shake at life.
Letting go of a loved one is perhaps the most difficult challenge we may come to face. Understandably, during these times our judgment becomes clouded and decision making unintentionally selfish. But we must keep things in perspective and therein lies the value of an advance directive and having constructive conversations about death. We ensure we’re on the same page, empowering our families to act with mercy and in our best interest when that day arrives. It’s never too early to discuss and it’s a topic that deserves attention. Turning a blind eye does not offer immortality.
The financial implications of such conversations and prepared documents are simply an added benefit, albeit substantial. For perspective, in 2011, Medicare spending reached $554.3 billion.[3] Thirty percent of that is attributed to 5 percent of Medicare beneficiaries who die each year, and diving one level further, one-third is incurred during the final month of life.[4] In fact, per-capita spending is six times greater for those who have died than those living.[4] This calls into question the effectiveness of expensive care that the dying receive near the end of life. It also quantifies exactly how much we're spending during those final days on tests, treatments, and procedures, just to buy a few more hours, not without some suffering and often against the person’s desire.
With an aging population these discussions are absolutely critical. Without them, we will continue to err when it comes to treatment decisions that need made of behalf of our loved ones and costs will continue to skyrocket in a broken system. The next time you speak with your family, engage in these discussions and evaluate what steps you want taken should the situation arise. Sure, it might be an initially uncomfortable conversation but it’s a reality we must all face.
Death is perhaps the most taboo subject in American culture, and unnecessarily so. It is the only absolute. If the concept makes you nervous, now is great time to realign and focus back in on your passions. You only get one shot at this thing. If you have the courage to live life true to yourself there will be no room for regret as you near your final breath. The same can be said for your loved ones. These conversations can bring clarity to challenging situations and allow you to act in the best interest of the ones closest to you.
Early in life, it’s about fighting, chasing your dreams with every ounce of strength you can muster, and never giving up. Live this way, but do not let it cloud your judgment when you’re beside someone nearing the final moments of their life. The same mindset does not apply, nor should it. When the curtains begin to close, the vast majority prefer to be made comfortable, reflect on a life well lived, and meet the end with dignity.
[1] Joffe-Walt, Chana. "The Town Where Everyone Talks About Death." NPR, 5 Mar. 2014. Web.
[2] Barnato, Amber E., et al. "Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?" Med Care 45.5 (2007): 386-93. Web.
[3] "NHE Fact Sheet." Centers for Medicare & Medicaid Services. National Health Expenditure Data, 9 Jan. 2013. Web.
[4] Barnato, Amber E., et al. "Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life." Health Services Research 39.2 (2004): 363-76. Web.