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The Honolulu Advertiser
Posted on: Wednesday, June 7, 2006

End-of-life care isn't always about medicine

It is often human nature to resist death rather than embrace it or accept it.

Families want to keep their loved ones around them as long as possible; individuals are often determined to keep at life as long as they can.

But these understandable impulses often result in decisions that are far from the best thing for the dying individual.

The latest example of this comes in a federally funded study released this week at a meeting of the American Society of Clinical Oncology.

Despite growing use of services such as hospice and increased awareness of the usefulness of palliative care, the study found that increasing numbers of cancer patients are experiencing chemotherapy in their last two weeks of life. It also found that increasing numbers of patients are being placed in intensive-care units in hospitals during their last month.

The overall percentage increases in these areas is relatively small, but the trend lines are disturbing.

It suggests that even when alternatives such as hospice and high-quality palliative care are available (and in many cases actually extend life), the choice is being made for expensive and often harsh medical treatment.

The answer, obviously, is not to deny top-flight medical care to those who want it or need it. But from a humane and financial standpoint, it makes little sense to subject people to treatment that will have no real impact on their life expectancy.

Hawai'i has some active efforts in moving toward a more comprehensive palliative care system. But according to the Hawai'i Medical Services Association, we still have the fourth highest rate of hospital-based deaths in the nation.

That's not necessary, nor is it necessarily in the best interest of patients and their families.

HMSA is actually in the final stages of a two-year study, using federal plan members, to determine how best to balance traditional medical services and other approaches such as home healthcare and hospice.

The goal is not to push people into one approach or another, but to find the best balance that serves the needs of the individual and creates the greatest quality of life.

At Kaiser Permanente, a pilot program is under way to extend palliative care (in conjunction with other medical care as needed) beyond the six-month period that Medicare normally imposes on traditional hospice programs. That's the right approach, and if fully embraced will eventually reverse the trend lines found in this week's study.