Avoiding a "death panel" redux

Facing Death: A Critical Analysis of Advance Care Planning in the United States

Studies have shown that advanced care planning improves communication and reduces suffering for patients and their bereaved caregivers. Despite this knowledge, the rates of advance care plans are low and physicians, as the primary gatekeepers, have made little progress in improving their rates. Through the lens of critical social theory, we examine these forces and identify the ideologies, assumptions, and social structures that curtail completion of advanced care plans such as Preserving Life, Ageism, Paternalism, and Market-Driven Healthcare System. A critical discourse provides suggestions to eliminate oppressive ideologies that act as barriers to advanced care planning.

Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations

BACKGROUND

While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care.

AIM

This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context.

DESIGN

We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions.

RESULTS AND DISCUSSION

Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings.

NORMATIVE APPRAISAL

Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks.

CONCLUSION

The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.

Duties to kin through a tragi-comic lens

Euripides' Alcestis (1959) raises the issue of ethical duties within families and exposes the romantic postures and rhetoric that can dominate such discussions. Should anybody be asked to sacrifice themselves or even undergo significant health risks for members of their own family? (An issue that is also relevant in considering our duties to future generations in terms of the earth we leave to them.) The issue that is dramatized to a heroic level in Alcestis arises in live organ and tissue donation within a family and challenges the idea that families should be trusted to sort out solutions that they can all live with. Alcestis intensifies the debate because the sacrifice of one life for another is its topic but, in doing so, it exposes many traps lying in wait for ethicists and medical jurists who boldly enter such debates (where emotions create shifting ground on which angels fear to tread).