4. explores ethical implications of the evolution of end-of-life care for case . The Ethical Intersection: Death With Dignity Meets Shared Decision Making . ( Economist Insights), which compared end-of-life care in 80 countries, the United . This looks at the costs of extending the end of life by a short period of time and tries to draw a boundary between those cases when treatment. Evaluation of End of Life Care (EconEndLife) is a European Research Council funded project, being The project's advisory group and ethics group meet annually. Care Measure (ICECAP-SCM) for use in economic evaluation at end of life.
Biased risk selection arises when insurance is voluntary or when people can choose among health plans with different features. Plans that disproportionately attract the sick will cost more than those that attract healthier people.
Medicare is virtually universal for Americans aged 65 and over, which limits selection problems. Nonetheless, many beneficiaries voluntarily purchase supplemental coverage, and others voluntarily enroll in certified managed care plans; both choices may generate problems related to adverse selection.
A particular concern is that competitive health plans may find it more economically attractive to compete on the basis of risk selection i.
Although insurance increases access to care, those without insurance do not necessarily go untreated, especially when they have acute or life-threatening problems Hafner-Eaton, Emergency departments are forbidden by law from turning away critically ill people for lack of insurance or other financial resources.
If an uninsured person is admitted for care and dies, the expenses incurred may be absorbed by the hospital and, when possible, passed on indirectly to other payers or covered by special public or charitable funds. If the person survives but is expected to remain seriously ill, efforts may be made to qualify the individual for public insurance or arrange a transfer to a public facility.
End-of-Life Care Interventions: An Economic Analysis
As medical care and hospital services became more effective and expensive, attempts began to be made to insure hospital care. Attempts to cover inpatient physician services followed. In the United States, several attempts since the early s to establish national health insurance have been turned back. After World War II, a variety of factors encouraged a significant growth in the scope of private health insurance.
Spotlight on Research
Although perhaps half of those over age 65 had some form of insurance by the early s, the difficulties faced by many older people in securing private health insurance eventually led to the adoption of Medicare. Page Share Cite Suggested Citation: Health plans vary in the services they cover, and even for covered services, other restrictions, such as requirements for prior approval of hospitalization, may apply IOM, In addition to limiting costs, the objectives of such requirements may be to improve quality of care by reducing departures from those clinical practices associated with better outcomes, to reduce patient care for which risks exceed probable benefits, or to limit exposure to iatrogenic care-induced illness.
Health plan restrictions that may particularly affect people with advanced illness come in many forms.
These include limiting the scope or level of benefits to restrict costs and encourage economical choices by consumers. Some services may be excluded altogether; for example, Medicare excludes payment for most outpatient prescription medications. In addition, plans may require patients to pay part of the cost of a service in the form of deductibles, copayments, or coinsurancecover a limited number of visits or days of care, or set a cap on the dollar amount of payments for selected or all services during a defined time period.
Some plans including Medicare set no upper limit on beneficiary liability for cost-sharing. Plans may establish a fixed payment per day, per case, or per capita regardless of the amount of service rendered. Some health plans are paid by employers, governments, or others on a capitated per member per month basis, but they may pay practitioners and providers on a fee-for-service, per case, or other basis, or they may combine partial capitation with other payments.
Many health plans insist that special personnel review hospital admissions, medical procedures, and certain other services. They may also require that a designated primary care physician authorize referrals to specialists.
Plans may adopt written statements that define what services are to be provided for particular medical problems, what medications are covered e. Such schedules may limit the time physicians can spend in evaluating patients, identifying problems and concerns such as depression or persistent painand discussing care options.
Patients may be covered only if they use providers that have contracts with or are employed by the health plan or if they obtain explicit authorization—and pay more—for the use of out-of-plan care. Depending on the characteristics of the provider network, patients may find specialist expertise unavailable for some problems, appointments hard to get, or travel requirements difficult.
The label managed care is often applied to health plans that employ one or more of the last six strategies listed above, although some use more restrictive definitions that focus on one strategy e.
This report follows the less restrictive usage. In any case, the report's major concern is not with organizational labels but with specific incentives and actions that may particularly affect those with advanced illness.
- End-of-Life Care Interventions: An Economic Analysis
- Looking for other ways to read this?
Chapter 4 has already considered some of the concerns about incentives used by managed care plans, which cover approximately 1 Medicare beneficiary in 10 with some states having considerably higher proportions. Financing Issues by Type of Service Although care at the end of life is often associated with hospice services, this report has pointed out that only a small percentage of Medicare beneficiaries qualify for hospice benefits.
Despite a general shift of care from hospitals to homes for both financial reasons and personal preferences, most older individuals still die in institutional settings, especially hospitals.
Hospitals also play a major role in caring for incurably ill people who subsequently die elsewhere. Thus, the following discussion first considers hospitals, then nursing homes, hospice, and home care. The emphasis here is on the traditional, fee-for-service Medicare program and the possible effects of its financing provisions on care at the end of life.
A later section considers Medicare managed care. This ultimately results in holistic suffering instead of holistic care for the dying person and the family. Initial work, published inhighlighted on limiting life-prolonging interventions and providing palliative care towards the end of life, in Indian intensive care units ICU.
Principles of a good death Principles of a good death involve the ability to know when the death is approaching, have physical symptoms well—controlled, patient centered needs met, right to die in a dignified manner at a place of choice and without life needlessly prolonged with artificial means [ Table 1 ]. The process of dying is usually recognized by the change in physiology, such as, failing vital parameters, decreased movement, decreased spontaneous verbalization, decreased intake of food and fluid and skin changes such as greyish mottling and cooling of peripheries, etc.
These could be helpful pointers to suggest poor prognosis and very limited life expectancy. However it is not always easy to predict impending death, and the best approach is to treat a possible reversible cause whilst accepting that the patient might be dying [ Table 4 ]. The decision makers should always be the primary care givers, in consultation with the palliative care team. The key EOLC communication should include prognostication, discussion on resuscitation, advance care planning and end of life symptoms [ Figure 1 ].
Despite many studies and data about prognosis and life expectancy, the best estimates still carry a high degree of uncertainty. Sixteen social workers in Israel were interviewed about their experiences with and attitudes towards various forms of euthanasia, as well as the meanings they ascribe to them.
Using phenomenological analysis, seven themes were identified, emphasizing individual, interpersonal, organizational, social, and therapeutic considerations, and suggesting a holistic and integrative structure of the phenomenon.
The themes were arrived at by identifying distinctions and similarities between different forms of euthanasia.
Two themes suggesting similarities were revealed: Given their unique position, social workers should participate in legal, social, and therapeutic discussions concerning end-of-life decisions for the benefit of clients, their families, and health-care providers.
Berkman, Peter Maramaldi, Emily A. Research has learned much in the past 40 years about the factors critical in a gerontological social work assessment. However, assessment must be constantly readdressed, because the context of health care changes and the research technology that enables the study of factors critical to the assessment process become more sophisticated.
University of KansasPhD, Aug. A qualitative study based on interviews with 16 terminally ill older adults with a high level of quality of life and their caregivers was conducted to examine the meaning of psychosocial and spiritual well-being during the final months and the process to attain it. Six primary contributing components to their psychosocial and spiritual well-being were identified: The findings highlight different ways that these elders grounded their resiliency: The author urges the profession to envision social work with terminally ill older adults beyond a viewpoint of coping and adaptation.
End-Of-Life Care | Social Work Policy Institute
Implications link the re-conceptualization of quality of life and identified areas of resiliency. Analyzing End-of-Life Care Legislation: A Social Work Perspective. Social Work in Health Care, 33 1 Several policy approaches are currently being considered in an attempt to organize a national response to the crisis surrounding quality end-of-life care.
Recent health care efforts aimed at supporting individuals facing advanced illness are marked by debate over assisted suicide, untimely referrals to hospice care, inconsistent adherence to advance directives, and substantive amounts of unrelieved pain in the end of life.
Social workers require a clear understanding of the current political and social climate if they are to navigate the ethical dilemmas as they are presented in end-of-life care.
This article discusses recently proposed policy response to the various political and social controversies surrounding end-of-life care for individuals facing advanced illness.
The analysis suggests criteria for evaluating end-of-life policy in general and offers a framework for evaluating proposed legislation. Suggestions for making end-of-life policy more effective and areas for future research are proposed. Finally, the implications of this policy analysis for social work are delineated.
Values Underlying End-of-Life Decisions: A Qualitative Approach Leichtentritt, R. Health and Soci al Work, 26 3 The purpose of the study discussed in this article was to reveal the values that would receive priority attention when considering end-of-life decisions.PHARMAC seminar: Palliative care, 1a of 6: Managing pain in palliative care
Nineteen elderly Israelis and their 28 family members participated in individual interviews that were analyzed using a hermeneutic phenomenological method.
Analysis of the transcripts indicated that participants considered a unique set of value priorities that raised different considerations in each of four domains of life: Three transcendent values crossed all four life domains: These value considerations are useful information for social workers who consult patients and family members at times of end-of-life decisions.
In a variety of settings, particularly within health care, social workers are educating clients about advance directives as well as being involved in end-of-life medical decision-making discussions.
The author explores some of the issues that have been identified through research as part of this complicated process. Social Work in Health Care, 30 2 Insufficient training of health professionals has often been cited as a major barrier to improving the system of care for dying patients and for the bereaved.
Although specific problems have been identified for physicians and nurses, the problems of social work in this substantive area have only recently been explored. This study used a practitioner survey, focus groups, and a survey of social work school faculty to broaden the information base. Results suggested that, not unlike the professions of medicine and nursing, social work knowledge and skill development in the care of the dying is uneven and not integrated sufficiently with theoretical concepts and research.
They recognized few social work scholars who could function as role models by providing comprehensive training, knowledge building, innovation, and advocacy.
A program for leadership development was created to test new approaches to professional development in the care of the dying and the bereaved. Fewer hospitalizations and decreased lengths of stay in the hospital have resulted in an increased need for extensive support services and continuing care planning for elderly people in primary care. Early identification of elderly patients needing community and hospital non-medical services is necessary so that timely, appropriate services can be delivered.