What We Talk About When We Talk About Dying: Affordable Care and the Subtext of Death

Tim Ihrig, MD, is a great believer in helping people die with dignity.

"I think culturally in medicine and more in society, we don't have the vernacular or the history to talk about the natural progression of life — that we will all die at some point," says Dr. Ihrig, a palliative care physician who practices in the Fort Dodge Region of Des Moines, Iowa-based UnityPoint Health. "You're not allowed to get sick or old in our society. Death is sometimes thought of as optional."

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For the kind of patients Dr. Ihrig sees, death is more a question of 'when' than 'if'; much of his work occurs in his patients' last two years of life. His job is make sure death, whenever it occurs, happens with as much dignity and comfort as possible, in a manner aligned with the values of each patient.

Quite frequently, this approach means patients use the healthcare system less than they otherwise might. "Bells and whistles don't potentiate quality or longer life expectancy in a majority of cases. They do just the opposite," says Dr. Ihrig of the method. "Fifteen percent of U.S. population takes 85 percent of healthcare dollar, and a majority of that is spent on futile care. [Palliative care] is not about withholding. It is about learning 'just because we can doesn't mean we should.'"

As Dr. Ihrig noted in a TEDx talk recorded in late 2013, palliative care patients, though they are the sickest patients in healthcare, are experiencing true value in care. As a group, they are spending two-thirds less money and are more at peace at a time when conventional wisdom says they should be suffering and in pain, than are patients who pursue "standard" treatment up to the very end. Accordingly, palliative care is an exception to a peculiar rule of U.S. healthcare, that less is hardly ever considered more.

Palliative care's way of achieving value in care is actually very simple: it defers to the patient at all times, securing patient engagement through expert communication about the patient as a human being. "Our job is to put together the bigger puzzle of everything that's going on. Until we understand the whole human being, we don't know where to go," says Dr. Ihrig. "We're transcending medicine to heal, not necessarily to cure, a person. Where we go from there is solely dependent on what that person values,'" he explains.

While explanations and an open ear seem like simple solutions, part of the reason they are exceptional is logistical. In many respects, the healthcare system of today is heavily tied to the healthcare system of 100 years ago, and 100 years ago serious illness was not so readily recognized. Recent developments in science and technology have made incredible advancements in detection and diagnosis possible, but they have also cemented an expert-centric mindset, which — in the words of Dr. Ihrig — emphasizes doing things to patients rather than doing things for them.

While most agree that patient-centered care is the direction in which care must move, for some providers it remains a controversial topic. While evidence seems to suggest patient-centered care will work in a vacuum, the healthcare system isn't quite set up to make the switch, and even where it is, patient-centered care requires cooperation, investment and initiative on the part of the patients.

Nevertheless, the development of patient-centered care systems is a major focus of the new healthcare system. Chronic care in particular is seeing value gains through patient-centered techniques, and for good reason. In the United States, 75 cents of every dollar spent in healthcare is spent on chronic care. Considering what the U.S. spends on healthcare, this is a vast sum of money. In 2013, the price tag for chronic care was about $2.1 trillion.

With the growing proportion of elderly people in the U.S. population — 10,000 baby boomers are turning 65 each day — barring serious changes, the elderly will continue to make up a growing portion of healthcare spending. Many of these elderly patients have end-stage chronic conditions, the kind that end up in Dr. Ihrig's wheelhouse — dementia, end-stage renal disease, cancer and really any progressive, irreversible disease with one eventual destination: death.

This demographic-fueled collision of chronic care and palliative care comes at an interesting time, when the burden of chronic conditions is increasing, discussions on patient-centered care are heated and the necessity of traditional healthcare spending is in question. It also comes at a time when the largest number of people in history are facing decisions about dying that aren't made any easier by a society that seems to want to live forever. "It's okay to choose as an option of care to do less or to focus on care and support — it is doing something. The system is not set up to see that," says Dr. Ihrig of end-of-life care.

Dr. Ihrig suspects the trajectory of end-stage chronic care will be a game-changer for healthcare, economics and the way the U.S. is structured in the next 30 to 40 years. "From this or that side of the aisle, people talk about death panels or withholding care. I never talk about withholding care. I talk about empowering somebody to know the truth and helping them so they can make best decision based on their values, and the rest takes care of itself. It's a simple answer, working for people," he says.

The model of palliative involvement is worth exploring because it sets the stage for relationships and connectivity from all providers, according to Dr. Ihrig: "Our role as palliative care physicians is to empower our colleagues to listen and hear patients. We're recognizing we [as physicians] need to be present for people in and out of the hospital. [Medicine] has to figure out how to meet patient needs in real time and become comfortable in that space, or it is going to fail."

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