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Rapid Responses: Rapid Responses published:
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Old and Not Dying - At What Cost?
- Peter A West (28 May 2004)
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Extreme ELPS
- Adam Jacobs (29 May 2004)
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Denying the obvious?
- Alfred P J Lake (14 June 2004)
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U.S. Rates of Hospitalization in the Last Years of Life
- Joanne Lynn (5 August 2004)
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Peter A West, Director YHEC, University of York, YO10 5NH
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The authors suggest that population ageing will not increase health care costs. This may be true of those dying, who incur a similar cost of death at any age. But this overlooks both the cost of elective care for older people and the cost of long term non-NHS care. If many of those dying in old age have elective procedures more than three years before death, their cost will not be included in this study. The authors note some data on low rates of surgical intervention in the dying group. Surely, if more people survive to old age, we will need more resources for hip replacements, eye and heart surgery and for long term care. Dying may be the end of a period of clinical activity with a similar cost at many ages but surely more older people means more surgery, treatment and care for the non-dying than currently. Competing interests: YHEC Ltd is a contract research company and works for the pharmaceutical industry, DH and the NHS. No conflicts exist in relation to this paper or comment. |
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Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
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In general, I heartily approve of the ELPS (electronic long, paper short) format that the BMJ uses for many of its papers. However, this time it seems to have been taken to extremes. It was very hard to follow the abridged version of this paper when the table with the most important results (number of days spent in hospital) had been banished to the web version. Please can we ensure that tables or graphs of primary results are always included in the abridged version? Competing interests: None declared |
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Alfred P J Lake, Consultant in Anaesthesia and Pain Management Glan Clwyd Hospital, LL17 0SU
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Spin is, it seems, an affliction not restricted to political machinations. Staff working in the health service see the problem in front of them on a daily basis as an inability to appropriately manage the old patient who may also be in the process of dying, albeit slowly. Unfortunately it is increasingly difficult to just die in hospital; one has to have a ‘cardiac arrest’ instead with all the unpleasantness that follows on from that before or after ticking the ‘admitted to ITU’ box. As dying in hospital becomes almost the norm GPs are, understandably, increasingly reluctant to leave the patient at home for fear of accusation that they didn’t do all that was ‘possible’. I have long been a supporter and advocate of the 'fair innings' argument but without the ‘third way’ of patient care being available, well ...... We do know what patients want and it’s not time in ITU, tubed, cannulated and festooned with wires and pipes. Euthanasia is not something to be feared, indeed in the future it may be something to be welcomed. Patients value good end-of-life care (1). The mean of 29.9 days spent in hospital in the last year fits with experience and it is quite simply the sheer numbers of elderly patients which threatens to overwhelm the system. 'Extremely elderly and terminally ill patient(s) consuming large amounts of resources shortly before death' is, in fact, born out by the authors' own figures as 77% of the 253779 deaths were aged 70 or above and indicates the scale of the problem. All patients, as they demonstrate, use significant resource in the final year(s) often to uncertain purpose, most not directed towards compassionate support and caring. These costs of dying are, really, an integral and significant part of the cost of aging until we as a caring society come to manage it better and we only fool ourselves if we don't admit it. 1. Bryce CL, Loewenstein G, Arnold RM, Schooler J, Wax RS, Angus DC. Quality of Death: Assessing the importance placed on end-of-life treatment in the intensive-care unit. Med Care 2004; 42: 423-31. Competing interests: None declared |
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Joanne Lynn, Director The Washington Home Center for Palliative Care Studies and RAND, Washington, DC 20016
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I thought that it might be helpful to know comparable data from the US. In 1996-1999, in the 5% sample of Medicare fee-for-service beneficiaries, 143,861 died outside of hospitals and 89,563 in hospitals, for a rate of dying in the hospital of 38.4%. Of course,some die in veteran's hospitals and other hospital settings that are not part of Medicare, but that is probably a small percentage, and those in managed care Medicare are lost from numerator and denominator. Even with these caveats, our rate is much lower than the rate that Dixon et al cite, which was 50-55%. Among those who died in the hospital, the mean rate of hospitalizations in the three years before dying is 3.82, with 34.2 days of hospitalization. This compares with the British rate of 2.2 hospitalizations and around 38 days. So, the US seems to have a few more hospitalizations, but much shorter hospitalizations. Among those who died in hospitals, 71% had 4 or fewer hospitalizations in their last three years. Among those who did not die in the hospital, our rates are not greatly different from those who did die in the hospital - 3.3 hospitalizations and 27.9 days in the hospital. Competing interests: None declared |
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