Starting a Necessary Conversation About Death

In 1789, Benjamin Franklin stated, “…in this world nothing can be said to be certain, except death and taxes.” Thus one of the most repeated quotes in American culture was born.  For centuries, our country has had national conversations about taxes and tax policy.  Taxation is a topic of discussion at our kitchen tables, town meetings and state capitols, and a source of neverending debate in Washington. However, no one wants to talk about death — at least not in any meaningful way.

According to the Medicare NewsGroup, somewhere between 25 percent and 30 percent of our annual Medicare spending is associated with care provided in the last 6 months of life.  According to the Congressional Budget Office, we spent $586 billion on Medicare in 2013.  That means that between $146 billion and $175 billion was spent on care provided in the last 6 months of life.

As a country, it is time that we have a serious conversation about having a serious conversation about death.  We should never put a dollar value on a single day of human life, but we must begin to talk about what we value as individuals, as families, and as a society.

Do we value the time a family physician spends counseling a terminal patient as she decides whether to cease treatment? Do we value the needs of the caretaker who is asked to make life or death choices for her husband at a time she feels least capable of making rational decisions? These are difficult conversations, but our discomfort with the topic of death and dying is contributing to poor public policy, substandard quality of end-of-life care for patients, and excessive spending on services with little or no benefit for the patient.

According to the Pew Research Center, 10,000 people will turn 65 each day through 2030. This means that in 2031, 20 percent of our population will be over the age of 65.  According to the Social Security Administration, a woman turning 65 today can expect to live, on average, until age 86.  A man can, on average, expect to live until age 84.  The aging of our population is to be celebrated, life expectancy continues to increase and we, collectively, are living longer lives.  This is in large part due to all of the accomplishments we have made in medicine over the last century, but it will have a lasting impact on every aspect of our economy, from our personal finances to our federal budget.

Over the past two decades we have made significant improvements in hospice and palliative care by placing an emphasis on these services and their positive impact on patients’ quality of life.  Patients, physicians, and care givers are more aware and informed about these services and the impact they can have on quality of life.  However, do we know what is happening to these patients in the weeks and months prior? Are we investing in services to improve their quality of life, are we providing support services to their caregivers, or are we simply extending the quantity of days? A larger question is must we always consider these options in isolation from each other or can we do both?

Conversations about death and dying are inherently difficult for patients, families, and their physicians.  These conversations are especially tryingat the moments in time that they typically arise – when death is imminent.  It is time that we are honest with ourselves as a society that death is a reality for all of us.

The hyperbole that has been associated with this topic inhibits progress and cuts off a desperately needed national conversation.  This is why it is important for us to create pathways that allow for a safe and honest discussion between patients, their physicians, and their families regarding end-of-life care. In a similar vein, elected officials in Washington and state capitols need to be able to engage in a substantive policy dialogue about death and dying… without risking their own political demise.
Shawn Martin is the vice president of advocacy at the American Academy of Family Physicians.