Annals of Long Term Care

Many individuals will receive their end-of-life care in long-term care settings. Nursing home residents with life-limiting illness may or may not be formally enrolled in a hospice program, but in either case are entitled to appropriate care at the end of life.1 The broader proposition is that it is or should be a societal norm to value providing compassionate end-of life care to persons across the continuum of care settings. An important question to consider is how well or poorly the current economic and regulatory frameworks support the quality of end-of-life care that nursing home residents are entitled to receive.

It is often problematic to apply traditional concepts of cost-benefit analysis to the value of geriatric care in general, and to end-of-life care in particular. The economic analyses that traditionally are done under the cost-benefit rubric tend to weigh strongly against care of the older individual.2 The argument often offered is that in a world of limited resources, hard choices have to be made in healthcare resource allocation, and that those choices should be guided by the cost per quality-adjusted life-year (QALY) saved. In this metric, one might undertake those interventions that cost no more than, for example, $100,000 per life-year saved in good health, and proportionately reduce the value assigned if the lengthening of life is of reduced quality because of comorbidity.

The limits of this kind of analysis are starkest when one considers end-of-life issues. High-quality end-of-life care is not likely to extend lifespan much, or at all, but rather is aimed at improving the quality of a brief span of life. At the extreme, one might make a very effective multimodality palliative intervention (with effective pain control, emotional support, and other compassionate measures), but do so very late in the course, and thereby make the patient’s last few days of life much improved in quality. Most patients and families would value such a quality-of-care intervention greatly, yet the brevity of lifespan affected means that on the QALY metric it might only be worth a few hundred dollars, since it only yields a fraction of a percent of a quality-adjusted life-year.

Alternatively, consider a rather different metric for placing a value on end-of-life services. It’s not one that is as commonly used, but it illustrates how much the conclusions reached are influenced by the criteria used. Focus not on the cost to society of publicly provided benefits, but rather on the rational choices of individuals for themselves, as they may allocate their own resources. This would reflect the kind of care people would choose for themselves if they had the choice to make, and acted as strictly rational and self-interested economic beings.

Persons with rational economic thinking—in this case, the rational decisionmakers at end of life—would spend almost as much as they could on anything that could improve the quality of their end of life by even a little. The more assets they have, and the shorter their anticipated survival, the more they’d be willing to pay per day on end-of-life care.

Even for those individuals who are without means, one would presumably want to provide them with end-of-life healthcare that is some reasonable approximation of the choices that those who are not impoverished would make for themselves at end of life. On this model, therefore, you would accord a very high social value to the provision of high-quality end-oflife care.

The fundamental point is that while models are interesting, they should be approached with some caution. This is particularly true when one can set up two plausible models, QALY and the economic decisionmaker, which are polar opposites in how they value end-of-life care. It seems reasonable when two models disagree so fundamentally to treat both with a healthy skepticism.