A study of the 1.8 million Medicare beneficiaries who died in 2008 showed that 20 percent had in-patient surgery in the last month of life and 10 percent had such surgery in the last week of their lives.
Further analysis of these numbers by researchers at the Harvard School of Public Health showed that nearly 25 percent of these surgeries were conducted on people older than age 80. The likelihood of having surgery at this age depended heavily on whether there were hospital beds available -- the more available beds, the more the region spent on Medicare, and the more likely it was that the oldest Medicare recipients would have surgery in the weeks before they died.
Lead author Dr. Ashish Jha suggested that the bottom line is "payment systems that reward quantity of care over the quality and appropriateness of care."
Dr. Amy Kelley, an internist with a specialty in geriatrics and palliative care who practices at Mount Sinai School of Medicine in New York City, provided commentary in the medical journal publication of this study. I talked to her about what families and patients who find themselves struggling with end-of-life care decisions can do to make sure that they get the kind of care they want. Kelley, whose patients are primarily people living in retirement, says the decision about surgery is always very individual.
"If surgery improves symptoms, fixes something that is painful, and extends life, then it might be the right decision. But for many other patients, it's in conflict with their goals. If your goal is to spend more time with loved ones and be out of the hospital, then surgery works against that."
One of the challenges is to write a living will or other advance directive describing your preferences that will hold up wherever you are when you need it, Kelley says. For instance, the laws are different in Florida than they are in New York. If you're able to make your own wishes known and all family members are in agreement, this probably isn't a problem, she says, so one of a family's goals should be to talk about these issues in advance. "Designate a power of attorney and make sure your loved one knows your wishes and why you have those wishes," she says.
One of the best resources for families facing this kind of crisis, Kelley says, is the services of a palliative care physician, whose job includes coordinating care in the best interest of the patient. Recent Medicare regulations require hospitals to make palliative services available. Kelley says families who want this service should first ask the physician in charge. If that isn't fruitful, then ask the hospital's patient care representative. She says palliative care is distinct from hospice care, appropriate for all kinds of patients, including those who aren't on verge of death.
Kelley says having these kinds of conversations are key to managing healthcare and its costs at every stage of life, but particularly so as a part of retirement planning. "We should talk with parents, spouses and siblings so we understand what makes someone's life worth living and what we should be fighting for."