Bankrupting the Medicare System – End of Life Issues

Medicare“R.D.” is 95 years old. She is frail, somewhat confused and remains in atrial fibrillation as her primary heart rhythm.  Atrial Fibrillation predisposes the patient to embolic strokes so the patient has been on anticoagulants or blood thinners for years to prevent these strokes.  Her unsteady gait and frail state have resulted in numerous falls. With each fall she bangs her legs and develops an accumulation of blood under the skin and in the soft tissues known as a hematoma. These are compressed, surgically drained and nursed to health with the help of wound care physicians and nurses who treat the patient at their office and at the patient’s home.  The process of healing is painful and takes weeks to months.  Just when we believe we have one wound under control the patient falls again and we start over. The patient is affluent and lives in her own large beautifully furnished apartment with the assistance of long term fulltime aides who care for her as if she was their own mother. Her children and grandchildren supervise the care and honor and respect their elder matriarch with the love and tenderness this sweet woman deserves.  We have discussed stopping the anticoagulant because the risk of severe injury from post-traumatic bleeding is now higher than the risk of a stroke if she is off the blood thinner. The family is fearful of a stroke robbing her of whatever existing independence and function she possesses and has declined that option repeatedly.

R.D. has a living will and has executed a “Do Not Resuscitate” form. Her home has been safety evaluated and adapted to limit or prevent falls.  Home oxygen has been supplied to keep her oxygen carrying capacity at a comfortable level. 

Due to her frail nature she fell again on her way to bathroom. She didn’t call her aide to assist her to the bathroom but the aide heard the fall.  The aide’s first instinct was to call 911.  The paramedics arrived and recommended transfer to the ER.  Despite a DNR form, a request for non-heroic actions and ongoing care by a team of physicians and nurses the patient ended up in an acute care hospital ER. A CT of the brain showed no cerebral bleeding. Her wounds were cleaned and antibiotics started. After 48 hours in the hospital she was ready to go home.  A friend of the family suggested a consult with Hospice. The full time aide wondered why they needed hospice. The children wanted “no stone left unturned” in providing care.

I happened to be out of town while the request for a hospice consult was made by the family. It was made to a physician who knows the patient and was covering the practice in my absence. He questioned what role hospice would play that the current caregivers were not already providing.  By the time I became aware of the request, the back and forth discussions had unfortunately turned contentious.  He and I, in my absence, were fired as care providers and hospice took over. Sedating medication was prescribed by the hospice medical director.  The patient expired from medication related issues before my return to town within 48 hours. She was essentially legally euthanized. 

In our community there are four hospice services. They are all for-profit making businesses. They do an outstanding job of relieving pain and providing comfort for dying patients and providing respite and comfort to family members. One of the agencies is known to be more aggressive with medicine than the others and when they are called in the patient sometimes expires quickly and much sooner than expected.  Since changing from volunteer agencies with no Medicare funding to for-profit institutions with Medicare and insurance coverage the hospice services have lost much of the warm personal touch.

This patient had excellent at home care and coverage.  End of life issues had been reviewed with the patient and family in advance of her decline. Despite this, changes are routinely made to the care plan as the patient’s health declines. The cost of these changes is billed to Medicare and we all pay for it. Patients who requested to be kept at home are transported to hospitals. Patients who have a complete and competent care team have well-meaning but desperate family members change the plan. It happens regularly and the services requested are often no more compassionate or comprehensive than the original plan and services but they are billed to, and paid for, by Medicare.  As long as the patient and family are not responsible for the bill the services will be provided whether they are truly needed or not even if the services are already available and being paid for privately by non-Medicare sources.

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