the graying of america challenges and controversies spring 20.docx

the graying of america: challenges and controversies spring
2012 17
Can Health Care
Rationing Ever
Be Rational?
David A. Gruenewald
Case Study
Mr. M. was a 77-year-old decisionally incapacitated
long-term nursing home resident with chronic schizo-
phrenia who was admitted to the hospital with a
bacterial pneumonia. His past medical history was
notable for deteriorating functional status over the
past 2-3 years, urinary retention requiring chronic
indwelling bladder catheterization, and two recent
hospitalizations for urinary tract infections leading
to sepsis. He developed respiratory failure soon after
admission and was intubated and placed on mechani-
cal ventilation. Follow-up studies suggested worsen-
ing pneumonia and acute respiratory distress syn-
drome (ARDS), as well as worsening kidney function.
The patient was unable to participate in any decision
making. His guardian requested that cardiopulmo-
nary resuscitation and all other intensive care be pro-
vided if necessary, including dialysis should Mr. M.’s
kidney failure continue to worsen. After five days of
mechanical ventilation, the patient was weaned from
the ventilator and extubated. The palliative care ser-
vice was consulted following the extubation; his criti-
cal care team questioned whether it would be appro-
priate to re-intubate the patient if he again developed

respiratory failure. The palliative care team contacted
Mr. M.’s brother, his only living relative, who felt the
patient’s quality of life was poor and believed the
patient would not want aggressive medical care. The
staff at his nursing home was contacted, as well as
the patient’s mental health case manager, who had all
known Mr. M. for many years. All concurred with his
brother’s assessment. Additionally, the nursing home
staff said that Mr. M. would not be able to return there
if the plan was to continue more intensive medical
management of his worsening health conditions. Hos-
pice care was discussed with these parties, and it was
thought that choosing hospice would best represent
the patient’s wishes under the circumstances. The pal-
liative care team contacted his guardian and explained
the patient’s medical situation and its implications
for his ongoing care (including the need for physical
restraints, loss of stable nursing home placement, and
confinement to the acute care hospital environment
for the duration of his acute illness). Based on this new
David A. Gruenewald, M.D., is an Associate Professor of
Medicine at the University of Washington School of Medi-
cine in Seattle, Washington, and the Associate Director of the
Palliative Medicine Fellowship at the University of Wash-
ington. He is the Medical Director of the Palliative Care and
Hospice Service at VA Puget Sound Health Care System in
Seattle, Washington. He received his Bachelor of Arts (B. A.)
degree from Reed College in Portland, Oregon, and his Medical
Doctor (M.D.) degree from the University of Chicago/Pritzker
School of Medicine in Chicago, Illinois.
18 journal of law, medicine & ethics

S Y M P O S I U M
information, his guardian concurred with the pallia-
tive care team’s recommendation for hospice care. The
patient’s respiratory status deteriorated again soon
after that, and he died comfortably two days later on
the medical ward without returning to the intensive
care unit.
Introduction
“ The vast machinery of modern medicine, which
can be heroically invoked to save a premature
baby, when visited upon an equally vulnerable and
failing great-grandmother, may not save her life so
much as torturously and inhumanely complicate
her dying.”
-Dennis McCullough1
Many Americans have come to expect that modern
medicine will continually increase both the quality
and the quantity of their lives. These expectations
are fuelled by reports in the popular media extolling
the benefits of the latest medical discoveries. When
it comes to their health care, many Americans living
today feel there should be no boundaries or limita-
tions on their access to the best providers and the lat-
est technologies.2 Nevertheless, increasing limitations
on health care expenditures are likely to occur sooner
rather than later. The United States spends over 16%
of its GDP on health care, 2.5 times more per person
than any other industrialized country.3 The percent-
age of GDP allocated to health care is increasing at the
expense of other social needs such as education, pub-
lic safety, and environmental protection. If costs con-

tinue increasing at the current rate, a fifth of GDP will
go to health care by 2018. Federal Reserve Chairman
Ben Bernanke warned in 2008 that health care spend-
ing was eroding the nation’s overall economic health.4
Over the last 10 years health care insurance premiums
have increased by 131%, while wages have grown 38%
and inflation has increased by 28%.5 With a projected
massive increase in the population of older people who
are the heaviest users of health care, a shrinking base
of younger taxpayers, continually rising expectations
for living longer and better, enormous expenditures of
national capital to rescue the financial system and fund
wars, and global resource limits, our current health
care spending trajectory is simply unsustainable.
The history of attempts to control health care costs
in the United States through explicit rationing of ser-
vices (i.e., direct denial of publicly funded health care
benefits occurring when insufficient resources are
available for all who might benefit) is not encourag-
ing. Although many people accept the necessity of
explicit rationing in theory, they tend to reject ration-
ing when it comes to their own health care or the care
of people they are concerned about.6 Indeed, when
explicit health care rationing occurred at the point of
service under managed care plans in the 1990s and
early 2000s, Americans reacted strongly and nega-
tively to these restrictions.7 The current public debate
on health care reform is notable for an unprecedented
level of rumors, fear-mongering, and misinformation,
and much of it is spread at lightning speed via the
Internet. This has contributed to confusion and fear of
health care reform efforts on the part of the American
public, and to heightened concerns about a possible

hidden agenda to ration health care to older Ameri-
cans.8 Given this recent history, many U.S. health care
policymakers have understandably concluded that
serious discussions of health care rationing cannot
occur in a political context.9
By comparison to explicit rationing, implicit ration-
ing based on inability to pay seems attractive because
no responsibility or blame can be attached to any par-
ticular person or organization, but at the same time
it is capricious and discriminatory.10 Although most
Americans have some choice in the selection of public
or private health plans, for many poor, near-poor, and
self-employed people, the choices may be limited or
non-existent.
The consequences of implicit rationing by inability
to pay have been disastrous for many of the 46 million
Americans who have no health insurance (i.e., 15% of
the population) and the 25 million who have inade-
quate coverage.11 Health outcomes for uninsured peo-
ple are significantly worse than for insured people: one
With a projected massive increase in the population of older
people who are the
heaviest users of health care, a shrinking base of younger
taxpayers, continually
rising expectations for living longer and better, enormous
expenditures of
national capital to rescue the financial system and fund wars,
and global resource
limits, our current health care spending trajectory is simply
unsustainable.

2012 19
David A. Gruenewald
study found that uninsured adults have a 25% greater
chance of dying than insured adults.12 Noting that the
U.S. is the only major industrialized nation that does
not provide universal health coverage to its citizens,
many believe that our society has a moral obligation
to provide some level of basic health care to all regard-
less of ability to pay.13 Universal health care coverage
would help to correct the worst inequities of our cur-
rent system, but improved efficiency in health care
delivery and some form of explicit rationing will be
required in order to pay for the additional coverage.14
Many would agree that a fairer, above-board approach
to allocating health care resources grounded in solid
ethical practices would be preferable to implicit ration-
ing that lacks such an ethical foundation. However, for
the reasons noted above, pressure to cut health care
costs either through explicit or implicit rationing will
become increasingly intense unless ways acceptable
to the public are found to improve the efficiency of
the system or to moderate the perceived demand for
health care services. Accordingly, approaches must be
found to address both the supply side (through fair
allocation of health care resources) and the demand
side of the equation, and to find greater efficiencies in
care delivery.
Age as a Basis for Health Care Rationing
It has been argued that explicit age-based health care
rationing is required to control costs.15 This belief is

understandable; people over age 85 are the nation’s
fastest growing age group, and are the heaviest users
of health care services. In one study, if health care costs
for 25-29-year-olds were indexed at 100, then expen-
ditures for the 65-69-year-old group were 387.6, and
for those aged 85-89 years, 614.2.16 About a third of
Medicare expenditures are spent in the last year of life,
much of it for aggressive life-sustaining care. However,
serious concerns have been raised about the effects of
rationing by age as an official policy, and whether such
a policy would ever be accepted by modern society.17
Examples of ethical arguments for age-based
rationing of health care include the “fair innings”
argument, which holds that priority for scarce health
care resources should be given to younger people who
deserve the opportunity to live as many years as older
people who have already lived most of their anticipated
lifespan. This argument is intuitively appealing: if only
one ICU bed were available and two people of differing
ages with similar capacity to benefit and equal need
were being considered for the bed, then it would seem
fair to give the bed to the younger person who has
had less opportunity to live as many years.18 A second
example, the “natural lifespan” argument, asserts that
an important goal of health care is to avert premature
death, but when a natural lifespan has been lived, then
the goal should become the relief of suffering rather
than life prolongation. It is argued that using expen-
sive medical technology to prolong the lives of older
people harms the health needs of other groups and
harms social needs other than health care.19
However, for each of the arguments in favor of age-
based rationing, vehement ethical objections and

counter-arguments have been raised, including the
objection that all people have equal worth regardless
of their age, disability status, or other factors outside
their own control; that only the individual can judge
the value of his own life, and that it cannot be assumed
an older person no longer has important life goals
that he wishes to achieve.20 Additionally, it would be
extremely difficult to determine a specific age beyond
which life-prolonging care would no longer be pro-
vided, and age-based rationing discriminates against
women, who live longer on average than men.
After several decades of strong ethical disagree-
ments on age-based rationing, it seems highly unlikely
that rationing by age as an official policy would ever be
broadly accepted. Furthermore, regardless of the ethi-
cal merits of arguments favoring rationing of health
care by age, such arguments do not determine which
policies and practices would be fair, or whether they
could be implemented in practice. In light of these
and other longstanding disagreements on principles,
what approaches to health care cost control might be
broadly acceptable in our pluralistic and independent-
minded society, and at the same time achieve better
health outcomes for our population at large?
Creating an Open and Accountable Process
to Ensure That Decisions to Limit Health
Care Services Are Fair and Reasonable
Establishing a fair process for health care priority set-
ting will be easier than agreeing on principles. In rec-
ognition of this reality, a middle way between explicit
and implicit rationing known as “accountability for
reasonableness” has been suggested as a process to
reach agreement on what is fair and legitimate.21 A
fair rationing process, as for implicit rationing, would

not require that principles for rationing be estab-
lished in advance. However, in common with explicit
approaches to rationing, there would be openness
about the rationale that all affected parties can agree
is relevant. This process would allow for reasonable
disagreement on principles governing the setting of
priorities that would be expected in our pluralistic
society. There will be disagreements on many issues,
including how much to prioritize the needs of the
most disadvantaged people, whether to give younger
people who have not had a “fair innings” higher prior-
S Y M P O S I U M
ity for health care than older people, and whether to
apply market-based approaches or central regulation
to allocate resources.
The key elements of a fair accountability for reason-
ableness process include full transparency about the
grounds for decisions, decision making based on cri-
teria that stakeholders agree are relevant to meeting
health needs fairly, and procedures to revise decisions
in light of new evidence or concerns. Furthermore,
the agreed upon decision-making procedures must be
both practically feasible and enforceable.22
Maximizing the Efficiency of Health Care
Delivery and Minimizing Patient Harm from
Inappropriate Medical Interventions
Alongside the development of a fair process for alloca-
tion of health care resources, economic approaches are

needed to minimize wasteful and inappropriate health
care spending. About a third of U.S. medical costs are
for services that do not measurably improve health
outcomes or health care quality.23 Furthermore, strik-
ing regional variations in the cost of health care have
been documented by the Dartmouth Atlas of Health
Care, an ongoing project that uses Medicare data to
examine variations in the way health care is provided.
These studies show that the likelihood that patients
with advanced cancer will spend their final days in a
costly intensive care unit or at home depends largely
on where they live and the hospital where they receive
their care.24 Regional differences in health care spend-
ing reflect differences in practice patterns rather than
differences in population health or price of services,
with more inpatient- and specialist-oriented patterns
of care in regions with high per capita expenditures.25
Policymakers have sought approaches to health
care cost control with the potential to bring groups
with divergent political views and large stakeholders
together. It has been difficult to find common ground
between those favoring governmental regulation as
the best way to control costs — for example, by lim-
iting the supply of medical technology and facilities;
setting payment rates; or allowing government to
negotiate prices with the health care industry — and
those favoring market forces, e.g., through competi-
tion between health plans and informed choices by
health care consumers.26 Concerns remain regard-
ing whether market-style approaches can accomplish
fair allocation of health care resources in light of the
extent to which health care services vary in necessity,
demand, and patients’ sensitivity to price.27 However,
in a widely read essay, Atul Gawande observed that the
most important decision we face in choosing how to

control health care costs is not whether we create a
single-payer system or a mixture of public and private
insurance — it is whether we choose to reward leaders
who put the needs of patients first rather than profits
first.28
Studies of the cost-effectiveness of medical inter-
ventions demonstrate a huge range of incremental
cost per quality-adjusted life years (QALY) gained,
ranging from a negative net cost to millions of dollars
per QALY gained, leading the American College of
Physicians, among others, to call for cost-effectiveness
analysis to be a priority for comparative effectiveness
research.29 Some believe that health care costs can
be controlled at the same time health outcomes are
improved if inefficient providers can be induced to
adopt cost-effective health practices instead of cost-
ineffective ones. However, others have raised concerns
about cost-effectiveness research being used by the
government to justify health care rationing by lim-
iting use of treatments at the margin, i.e., expensive
treatments with small benefits. Still others feel that
cost-effectiveness arguments need not be used to con-
tain costs and that instead, thorough evaluation will
reveal that some interventions are of no benefit, or
even harmful.30
Receiving more health care services is not necessar-
ily better, and may in many cases be worse.31 Higher
intensity health care may result in net harm to patients
in several ways. For example, overuse of diagnostic
testing yields false positive results and exposes patient
to unnecessary treatments and emotional harms such
as anxiety related to testing and treatment; involve-
ment of more specialists results in discontinuity of

care; and unnecessary hospitalization exposes patients
to iatrogenic infections.32 Additionally, indirect harms
result from the opportunity cost of excessive and
wasteful health care spending that could instead be
spent in other ways to promote health or well-being
of the involved population. Providing an expensive
intervention of marginal value to one patient may
deprive many others of less expensive but more effec-
tive care — a form of implicit rationing.33 Expendi-
tures to promote health might be more efficiently used
in areas other than health care, and indirect harm may
result from the diversion of resources away from other
determinants of health, such as education, jobs, and
income.34
Now, systems reforms are receiving renewed atten-
tion as a way to contain costs and improve care that may
be broadly acceptable politically, including creation of
“smarter,” evidence-based health care systems; new
models for health care delivery such as the patient-
centered medical home and accountable care organi-
zation models; and payment incentives such as “pay for
performance” to improve quality and lower costs.35 The
patient-centered medical home model aims to create
2012 21
David A. Gruenewald
a strong primary care foundation within health care
systems, while the goal of the accountable care organi-
zation model is to align incentives and accountability
for providers across the care continuum.36 Based on

evidence that a strong focus on primary care improves
care quality while lowering costs, the patient-centered
medical home model emphasizes a coordinated, com-
prehensive care approach while incorporating elec-
tronic medical information systems, chronic disease
management across populations, continuous quality
improvement, improved reimbursement for primary
care, and rewards for high performance. Account-
able care organizations are provider-driven organiza-
tions responsible for a full continuum of care as well
as the costs and quality of care for a discrete patient
population. These organizations might take several
forms, including multispecialty practice groups either
with or without hospital ownership, large integrated
health care delivery systems, independent practice
associations, virtual interdependent networks of phy-
sician practices, or physician–hospital organizations.
Accountable care organizations would help to address
concerns regarding the implementation of patient-
centered medical homes such as establishing the
financial arrangements to allow primary care provid-
ers to benefit financially from improved performance,
and providing the capability to measure and monitor
care quality and to prevent potential overuse or under-
use of medical services.37 These models of care may
provide a more coordinated approach to health care
that facilitates better and more cost-effective end-of-
life care, while creating incentives for physicians and
systems to put the needs of their patients first.
Should Clinicians Be Expected to
Ration Health Care at the Bedside?
It has been observed that global budgeting, which
constrains the availability of resources such as operat-
ing theatre time or imaging equipment, relies largely

on implicit rationing at the point of service. Such clini-
cal priority setting has been acknowledged by some as
inevitable.38 In my experience, surgeons and others
who manage the clinical use of scarce resources (e.g.,
organs for transplant) are more comfortable with this
role than internists or intensivists. Although many cli-
nicians are reluctant to play a role in bedside ration-
ing,39 studies have reported that physicians can accept
a role in resource allocation when necessary, that they
can ration using clinical criteria such as severity of ill-
ness and prognosis, and that the public expects physi-
cians to provide leadership in determining resource-
allocation policies.40 And even ethicists who argue
vigorously against rationing health care services based
on age may agree that consideration of a person’s abil-
ity to benefit medically from an intervention is accept-
able.41 In practice, clinicians are obliged to make their
best recommendations for care to patients and their
families, who are often ill prepared to make decisions
on what should be done. The potential danger is that
clinical resource allocation and priority setting will be
done haphazardly at best, reflect the personal biases
of the clinician, or even be based on judgmental or
prejudicial behavior. To safeguard patients against
these hazards, clinicians should base such decisions
on guidelines grounded in the best available evidence
where possible, although clear guidance is not always
available. Much more work is needed to improve the
accountability and establish the legitimacy of health
care resource allocation decisions at both the bedside
level and at the level of health care systems.
Encouraging Approaches That Foster
Excellent End-of-Life Care: The Demand

Side of the Equation
All too often medical care intended to treat serious
acute illnesses has a markedly negative impact on the
way many frail older people spend their last months
or years of life. Many medical interventions may be
Accountable care organizations would help to address concerns
regarding the
implementation of patient-centered medical homes such as
establishing the
financial arrangements to allow primary care providers to
benefit financially from
improved performance, and providing the capability to measure
and monitor
care quality and to prevent potential overuse or underuse of
medical services.
These models of care may provide a more coordinated approach
to health care
that facilitates better and more cost-effective end-of-life care,
while creating
incentives for physicians and systems to put the needs of their
patients first.
S Y M P O S I U M
marginally beneficial and associated with substan-
tial burdens, especially in people near the end of life.
While modern medicine excels in managing acute
medical crises, it is less successful in the manage-
ment of chronic diseases and advancing frailty. Geri-

atrician Dennis McCullough observes that by apply-
ing standard medical approaches to the care of frail
older patients near the end of life, some are subjected
to “Death by Intensive Care,” spending their last days
sedated, in a state of delirium and hooked up to life-
support machines. All too commonly, “elders suffer the
accumulating burdens of illness and exhausting medi-
cal regimens that extract all their available energy and
time, leaving nothing left for living beyond a ‘medical-
ized’ life.”42
Some question whether physicians can determine
which of their very ill patients will benefit from expen-
sive care and which will die regardless of the care they
receive, and remain unconvinced that substantial
health care cost savings near the end of life are actu-
ally achievable without harming patients.43 However,
it is clear that patients near the end of life often receive
aggressive yet unwanted medical interventions. One
study found that only 30% of hospitalized patients
older than 80 years wanted care to prolong life, yet
63% received life-prolonging treatments such as car-
diopulmonary resuscitation, tube feeding, mechanical
ventilation, and dialysis.44 Although this unwanted
use of medical interventions is extremely common and
rarely is there ill intent, much more must be done to
prevent this sort of harm to patients. Dr. Daniel Ber-
wick commented that “using unwanted procedures
in terminal illness is a form of assault. In economic
terms, it is waste.” Berwick notes that “several tech-
niques, including advance directives and involvement
of patients and families in decision-making, have been
shown to reduce inappropriate care at the end of life,
leading to both lower cost and more humane care.”45
Advance care planning is good medicine. A recent
randomized controlled trial found that advance care

planning improved end-of-life care and patient and
family satisfaction and reduced stress, anxiety, and
depression in surviving relatives.46 Additionally, con-
versations about the goals of care between patients
with advanced cancer and their physicians are associ-
ated not only with better quality of life while dying, but
also with fewer life sustaining procedures and lower
health care costs in their final week of life.47 In shared
decision making, physicians work with patients and
families to consider the benefits and burdens of inter-
ventions and to make health care decisions, thereby
reducing the risk that patients will receive unwanted
medical interventions. However, the traditional model
of shared decision making assumes that patients and
families can evaluate options with their physicians
systematically, apply the available medical evidence
dispassionately to possible clinical scenarios, consider
the potential benefits and burdens of each option,
assess the likelihood of potential outcomes, and agree
on clear and rational decisions. Increasingly, it is being
appreciated that patients and families do not make
decisions in the same way that physicians do.48 By con-
trast, decisions made by patients and their families are
affected by a host of other factors including their prior
experiences of health care, the stresses associated with
acute illness, and fears of future complications, which
may give the impression that they are “in denial,” or
that their hopes are “unrealistic.”49
Newer models of shared decision making have been
proposed to take into account the dilemmas patients
and their families often face, such as the choice
between two unacceptable outcomes such as death
and long-term debilitation, and the difficulty in pre-
dicting what they both would want in future circum-

stances. In one such paradigm, the physician’s role in
guiding decisions will change over time in response to
changes in the patient’s health and factors such as the
predictability of the clinical outcome or the chance of
the patient returning to an acceptable quality of life.
Another model offers some steps clinicians can take
to prepare patients and their surrogate decision mak-
ers to make the best possible medical decisions in the
moment the decisions are required.50 Although these
and other refinements in models of shared decision
making still require testing and validation, hopefully
they will help improve patient-physician communi-
cation and decision making and ultimately minimize
unwanted and often costly medical interventions.
Despite the potentially large benefits of some form
of shared decision making, the majority of studies
show that most physicians engage in very little of
it.51 This is especially problematic in light of the fact
that older patients may be less likely than younger
people to ask clinicians for medical information, and
more apt to accept unquestioningly the advice of their
physicians.52 Fortunately, examples are available to
demonstrate that it is possible at the regional level to
provide patients with more information about their
health status and to give them a range of options for
care in addition to aggressive medical care as usual.
The regions that are most successful in accomplishing
these goals typically have community-level consensus
about the importance of asking about and document-
ing end-of-life preferences; they support training phy-
sicians to have these conversations with patients; and
they have put systems in place to support palliative
and hospice care.53 Another factor that contributes to
inappropriate health care spending is the clinician’s

2012 23
David A. Gruenewald
own emotional reaction to the decisions facing their
patients, especially when the outcomes of care are
uncertain and the consequences are dire. Like patients
and families, when the outcomes of medical interven-
tion are hard to predict, physicians may be concerned
that in the future they will regret or feel guilty for not
having done everything possible for the patient. Physi-
cians may wonder if there is just “one more thing” that
can be done, which may lead them to advise patients
and families to continue trying interventions with a
small likelihood of benefit, or to frame a choice in a
way that makes it more likely they will opt for con-
tinuing aggressive care. Physicians may also feel that
if aggressive treatment is stopped, then it will mean
that all the effort and money expended to that point
was wasted.54 Moreover, physicians may bring unrec-
ognized and poorly understood countertransference
issues to their interactions with patients that can lead
to inappropriate treatment recommendations. By
being aware of these potential pitfalls, clinicians can
consider whether their advice to patients and their
families truly honors what patients would want for
themselves under the circumstances.
As a palliative medicine physician and geriatrician,
many times I have heard dying and frail older patients
say, “I just want to go home,” or “I don’t want to be
kept alive on machines,” or “If I had known then what
I know now, I never would have started the treat-

ment.” As in the case of Mr. M., further exploration of
the patients’ or their surrogates’ concerns often reveals
that they would rather be made as comfortable as pos-
sible and allowed to live at home even if that means
forgoing treatments that could prolong their lives. For
these patients, the apparent “demand” for medically
intensive health care is false: it is simply that no one
took the time to find out what they really wanted, nor
were they offered a choice of anything more suited to
their needs. By attending to patients’ understanding
of the clinical situation and tailoring communications
to their needs, providers can help patients assess the
benefits and burdens of medical interventions, and
develop care plans that best meet their needs. When
aggressive life-prolonging treatments would more
likely prolong the dying process than enhance the
quality of a person’s remaining life, palliative medicine
and geriatrics providers often recommend withhold-
ing or withdrawing life-sustaining treatments. These
recommendations are often accepted if not welcomed
by patients, as well as by their surrogate decision mak-
ers who may feel burdened by the responsibility of
decision making for their loved one. In many but not
all cases, these goal-setting and care-planning discus-
sions result in avoidance of unwanted and expensive
interventions, and placement of the patient in a more
comfortable care environment.
Many frail elders, patients, and their families may
wish to consider “slow medicine” as an alternative to
medical care as usual (or its cousin hospice care when
appropriate). Slow medicine is a gentler, less aggres-
sive care approach intended to ease the inevitable,
irreversible decline of advanced age, rather than to
attempt to prolong life at the expense of quality of

life. McCullough describes slow medicine as a strategy
“where family, friends, and neighbors team up with an
elder and with health-care providers — including vis-
iting nurses and other home-based care providers —
to improve the quality of care and avoid inappropriate,
sometimes harmful care.”55 With slow medicine, the
focus is on excellent chronic care — attending to the
day-to-day needs of the patient “by offering emotional
support and social stimulation, supplying better nutri-
tion, and making sleeping, moving, bathing, dressing,
and voiding easier.”56 Families assisting their loved
ones in the slow medicine approach must raise the dif-
ficult subjects of advance care planning and surrogate
decision making with the patient’s physician, before
an acute crisis is upon them. Questions about the
patient’s ability to drive and to manage at home must
be addressed, and strategies devised to compensate
for problems that arise with independent function-
ing. Plans must be made in the event the frail elder
becomes unable to manage at home any longer, and
placement in a more supportive living environment
is needed. Meanwhile, the elder’s regimen of medica-
tions and other medical tests and treatments must be
subjected to regular, critical scrutiny; and time-tested,
low-risk interventions are often preferred over high-
tech but more exhausting regimens (e.g., home fecal
occult blood testing vs. colonoscopy). Slow medicine
is very hard work for families and other concerned
helpers who struggle to care for their aging and frail
loved ones. Most long-term care is uncompensated
care, falling on the backs of family members and sig-
nificant others. For patients and their families who
lack the time and resources to care for their loved ones
at home, slow medicine may not be possible. One of
the opportunity costs of spending so much on usual
care to prolong life is that correspondingly less money

remains to support home care by family and other
informal caregivers providing slow medicine.
To make it possible for more elders who want slow
medicine to have it, not only do we need more support
for family caregivers, we also need to pay providers
to have conversations with patients about their care
preferences. Ideally, these conversations about goals
of care near the end of life would happen over a longer
period of time with a trusted primary care provider.
S Y M P O S I U M
And more clinicians need to be trained how to have
these conversations effectively in a variety of settings,
from primary care clinics to nursing homes to intensive
care units. Palliative care physicians and geriatricians
may play a valuable role in training other clinicians
to have care planning conversations, although there
are still far too few practitioners of either specialty,
and too few in positions to train others. However, to
ensure that advance care planning and slow medicine
do not become additional tools to ration health care
covertly, we must take care not to use either as cost
containment strategies.57 They are appropriately used
only to ensure that the patient’s wishes for care are
understood and honored.
We now know that most Americans over the age of
80 years prefer comfort-oriented care over measures
intended to extend life.58 More must now be done to
ensure that medical care we provide to our elders con-

forms to the informed choices of patients and their
families. And in doing the right thing for them, we
may also find that the costs of unwanted and inappro-
priate health care interventions go down.
Note
The opinions expressed herein are those of the author and are
not
those of the Department of Veterans Affairs Health Care
System.
References
1. D. McCullough, “Grand Rounds: Slow Medicine,”
Dartmouth
Medicine Magazine 32, no. 3 (Spring 2008), available at
<http://dar tmed.dar tmouth.edu/spring08/html/grand_
rounds.php> (last visited November 16, 2011).
2. A. Owen-Smith, J. Coast, and J. Donovan, “‘I Can See
Where
They’re Coming From, But When You’re on the End of It…You
Just Want to Get the Money and the Drug’: Explaining Reac-
tions to Explicit Healthcare Rationing,” Social Science and
Med-
icine 68, no. 11 (2009): 1935-1942; D. Mechanic, “The Rise and
Fall of Managed Care,” Journal of Health and Social Behavior
45, Supp. (2004): 76-86.
3. J. Greene, “Who Will Get Care?” Trustee 61, no. 9 (2008):
8-11.
4. Id.
5. D. Altman, “Simple Arithmetic,” Pulling It Together, no. 24,
September 15, 2009, available at <http://www.kff.org/pullin-

gittogether/091509_altman.cfm> (last visited November 16,
2011).
6. See Owen-Smith et al. and Mechanic, supra note 2; D. Calla-
han, “Cost Control: Time to Get Serious,” New England Journal
of Medicine 361, no. 7 (August 13, 2009): e10.
7. See Mechanic, supra note 2.
8. P. Barry, “Health Care Reform: The Assault on Truth,”
AARP
Bulletin 50, no. 7 (September 2009): 12-16.
9. See Mechanic, supra note 2.
10. D. Callahan, “Symbols, Rationality, and Justice: Rationing
Health Care,” American Journal of Law & Medicine 18, nos. 1
and 2 (1992): 1-13; N. S. Jecker and R. A. Pearlman, “Ethical
Constraints on Rationing Medical Care by Age,” Journal of the
American Geriatrics Society 37, no. 11 (1989): 1067-1075.
11. See Greene, supra note 3.
12. K. Trotochaud, “Ethical Issues and Access to Healthcare,”
Jour-
nal of Infusion Nursing 29, no. 3 (2006): 165-170.
13. See Callahan, supra note 10; N. S. Jecker and R. A.
Pearlman,
“An Ethical Framework for Rationing Health Care,” Journal of
Medicine and Philosophy 17, no. 1 (1992): 79-96.
14. See Callahan, supra note 10.
15. D. Callahan, Setting Limits (New York: Simon & Schuster,
1987): at 23.
16. Productivity Commission, Economic Implications of an

Age-
ing Australia, April 12, 2005, at 148, 155, available at <http://
www.pc.gov.au/projects/study/ageing/docs/finalreport> (last
visited November 16, 2011).
17. R. ter Meulen, “Are There Limits to Solidarity with the
Elderly?”
Hastings Center Report 24, no. 5 (1994): 36-38.
18. C. M. Clarke, “Rationing Scarce Life-Sustaining Resources
on the Basis of Age,” Journal of Advanced Nursing 35, no. 5
(2001): 799-804.
19. See Callahan, supra note 15, at 118.
20. S. Giordano, “Respect for Equality and the Treatment of
the
Elderly: Declarations of Human Rights and Age-Based Ration-
ing,” Cambridge Quarterly of Healthcare Ethics 14, no. 1
(2005):
83-92; J. G. Evans, “The Rationing Debate: Rationing Health
Care by Age: The Case Against,” BMJ 314, no. 7083 (March 15,
1997): 822.
21. N. Daniels, Editorial, “Accountability for Reasonableness:
Establishing a Fair Process for Priority Setting Is Easier Than
Agreeing on Principles,” BMJ 321, no. 7272 (November 25,
2000): 1300-1301.
22. Id.
23. E. S. Fisher, Editorial, “More Medicine Is Not Better
Medicine,”
New York Times, December 1, 2003.
24. M. McKinney, Editorial, “Where You Live = How You

Die,”
Modern Healthcare 40, no. 47 (2010): 6-8.
25. E. S. Fisher, Editorial, “Medical Care – Is More Always
Better?”
New England Journal of Medicine 349, no. 17 (2003): 1665-
1667.
26. D. Altman, “The ‘Third School’ for Controlling Health
Care
Costs?” Pulling It Together, no. 27 (October 23, 2009), avail-
able at <http://www.kff.org/pullingittogether/102909_altman.
cfm> (last visited November, 2011).
27. S. D. Gould and N. M. Baum, Editorial, “Where Are We in
the Rationing Debate? Improved Tools and Public Participa-
tion Can Inform Fair Systems,” BMJ 337, no. 7675 (October 18,
2008): 883-884.
28. A. Gawande, “The Cost Conundrum: What a Texas Town
Can
Teach Us about Health Care,” New Yorker, June 1, 2009.
29. M. C. Weinstein and J. A. Skinner, “Comparative
Effectiveness
and Health Care Spending – Implications for Reform,” New
England Journal of Medicine 362, no. 5 (2010): 460-465.
30. Id.
31. See Gawande, supra note 28.
32. C. M. Kilo and E. B. Larson, Editorial, “Exploring the
Harmful
Effects of Health Care,” JAMA 302, no. 1 (2009): 89-91; see
Fisher, supra note 25.

33. See Gawande, supra note 28; id. (Kilo and Larson); C.
Donald-
son, A. Bate, P. Brambleby, and H. Waldner, “Moving Forward
on Rationing: An Economic View,” BMJ 337, no. 7675 (October
18, 2008): 905-906.
34. See Kilo and Larson, supra note 32.
35. See Altman, supra note 26.
36. D. R. Rittenhouse, S. M. Shortell, and E. S. Fisher,
“Perspective:
Primary Care and Accountable Care – Two Essential Elements
of Delivery-System Reform,” New England Journal of Medicine
361, no. 24 (2009): 2301-2303.
37. Id.
38. See Gould and Baum, supra note 27.
39. D. Strech, G. Persad, G. Marckmann, and M. Danis, “Are
Physi-
cians Willing to Ration Health Care? Conflicting Findings in a
Systematic Review of Survey Research,” Health Policy 90, no. 2
(2009): 113-124.
40. See Gould and Baum, supra note 27.
41. See Giordano, supra note 20; see Evans, supra note 20.
42. See McCullough, supra note 1.
2012 25
David A. Gruenewald

43. M. Feldstein, Editorial, “Obama’s Plan Isn’t the Answer,”
Wash-
ington Post, July 28, 2009.
44. E. Somogyi-Zalud, Z. Zhong, M. B. Hamel, and J. Lynn,
“The
Use of Life-Sustaining Treatments in Hospitalized Persons
Aged 80 and Older,” Journal of the American Geriatrics Society
50, no. 5 (2002): 930-934.
45. R. Pear, “Obama Returns to End-of-Life Plan that Caused
Stir,”
New York Times, December 25, 2010.
46. K. M. Detering, A. D. Hancock, M. C. Reade, and W.
Silvester,
“The Impact of Advance Care Planning on End of Life Care in
Elderly Patients: Randomised Controlled Trial,” BMJ 340, no.
7751 (2010): c1345; id. (Pear).
47. A. A. Wright, B. Zhang, A. Ray, J. W. Mack, E. Trice, T.
Balboni,
S. L. Mitchell, V. A. Jackson, S. D. Block, P. K. Maciejewski,
and H. G. Prigerson, “Associations between End-of-Life Dis-
cussions, Patient Mental Health, Medical Care Near Death,
and Caregiver Bereavement Adjustment,” JAMA 300, no. 14
(2008): 1665-1673; B. Zhang, A. A. Wright, H. A. Huskamp,
M. E. Nilsson, M. L. Maciejewski, C. C. Earle, S. D. Block, P.
K. Maciejewski, and H. G. Prigerson, “Health Care Costs in the
Last Week of Life: Associations with End-of-Life Conversa-
tions,” Archives of Internal Medicine 169, no. 5 (2009): 480-
488.
48. N. E. Goldstein, A. L. Back, and R. S. Morrison, “Titrating
Guidance: A Model to Guide Physicians in Assisting Patients
and Family Members Who Are Facing Complex Decisions,”

Archives of Internal Medicine 168, no. 16 (2008): 1733-1739.
49. Id.; G. B. Chapman and A. S. Elstein, “Cognitive Processes
and
Biases in Medical Decision Making,” in G. B. Chapman and F.
A. Sonnenberg, eds., Decision Making in Health Care: Theory,
Psychology, and Applications (New York: Cambridge Univer-
sity Press, 2000): at 183-210.
50. See Goldstein et al., supra note 48; R. L. Sudore and T. R.
Fried, “Redefining the ‘Planning’ in Advance Care Planning:
Preparing for End-of-Life Decision Making,” Annals of Internal
Medicine 153, no. 4 (2010): 256-261.
51. J. L. Hanson, Editorial, “Shared Decision Making: Have
We
Missed the Obvious?” Archives of Internal Medicine 168, no.
13
(2008): 1368-1370.
52. S. Turk-Charles, B. E. Meyerowitz, and M. Gatz, “Age
Differ-
ences in Information-Seeking among Cancer Patients,” Inter-
national Journal of Aging and Human Development 45, no. 2
(1997): 85-98; V. Jenkins, L. Fallowfield, and J. Saul, “Infor-
mation Needs of Patients with Cancer: Results from a Large
Study in UK Cancer Centres,” British Journal of Cancer 84, no.
1 (2001): 48-51; Z. Chouliara, N. Kearney, D. Stott, A. Molas-
siotis, and M. Miller, “Perceptions of Older People with Cancer
of Information, Decision Making and Treatment: A Systematic
Review of Selected Literature,” Annals of Oncology 15, no. 11
(2004): 1596-1602.
53. See McKinney, supra note 24.
54. See Goldstein et al., supra note 48.

55. See McCullough, supra note 1.
56. Id.
57. D. Callahan, “Controlling the Costs of Health Care for the
Elderly – Fair Means and Foul,” New England Journal of Medi-
cine 335, no. 10 (1996): 744-746.
58. See Somogyi-Zalud et al., supra note 44.
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