How much would you pay to live another year? This may seem unreasonable. After all, isn’t life the most precious commodity there is?
populations grow older, becoming physically more vulnerable, and healthcare budgets rise, this is a question health services around the world need to tackle. Life, and the later years in particular, come at a cost and health services are picking up a hefty portion of the tab.
study published in the claims that one year of extra life for cancer patients costs an average of $207,000, almost four times as much as it did in 1995. According to the US National Institute of Health, nearly 30% of all Medicare spending occurs during the last six months of a patient’s life. Journal of Economic Perspectives
To keep control of expenditure for the seriously ill or dying, many health services use cost-effectiveness scales. One of the most common is the
Quality-Adjusted Life Year (QALY) system: a drug that gives a patient a healthy extra year is worth one QALY, while treatment providing a year of so-so health would be 0.5 QALYs. Based on this, the UK health service, for example, has set a threshold of between £20,000 and £30,000 ($30,000-$43,000) to spend per QALY per patient.
We seem to spend more and more on prolonging life. This may be a mistake Dominic Wilson
Consequently, certain drugs are rejected as too expensive. At the end of 2015, a new breast cancer treatment failed to make the cut in the UK thanks to a price tag of £90,000 ($130,000) per patient. It was estimated to extend life by around six months. Many argue that any amount of precious time gained with loved ones is worth the expense, but with health service budgets strained, can postponing death by a few months at the expense of spending elsewhere be justified?
Dominic Wilkinson, intensive care doctor and director of medical ethics at the University of Oxford, understands the dilemma, despite the fact that, as a doctor, “our first duty is to help our patients, even if it is expensive.” Unfortunately, he says, what’s often buried beneath the desire to extend life is perhaps the most important aspect of all – what the patient wants.
An unfortunate result of some end-of-life treatments is the debilitating effect it can have on the body and mind. “We seem to spend more and more on prolonging life and providing treatment that means people spend more time in hospital, causing greater discomfort during the final phases of life,” says Wilkinson. “This may be a mistake.”
Rest in peace
a 2015 study found that advanced cancer patients placed greater emphasis on the quality of life during their last months than they did on simply extending it. The country’s health program requires most residents to pay for treatment from their own savings or Medisave medical savings accounts. Participants said they would be willing to spend around $8,000 to extend life by a year, almost half of what they would spend on palliative care that would allow them to die at home, even it meant a shorter life.
Caregivers were also surveyed, with doctors around three times more willing to pay to extend life by one year than their patients. “This shows caregivers are not always good at predicting what patients want and may be placing too much emphasis on life-extending treatment,” says
Chetna Malhotra, assistant professor at Duke-NUS Graduate Medical School Singapore and co-author of the study.
This was backed by a
2016 British Medical Association report into end-of-life care. Some doctors continued to provide treatment, even when it was not always in their patients’ best interests, it said, with fear of perceived failure and pressure from relatives the most common reasons. In many Asian countries, doctors actually collude with a patient’s family, Malhotra adds. “The patient may not even be fully away of their diagnosis or prognosis. They believe they are trying to protect the patient.” Re-focus on quality of life
In light of the survey’s findings, Malhotra would like to see a greater emphasis on palliative care that focuses on quality rather than quantity of life: “More needs to be done to raise the awareness and accessibility of this option.” Wilkinson believes there is still a stigma attached to it, a sense of giving up. “But that’s certainly not the case. It’s about making the most of what we have.”
The Singapore study shows that the willingness to pay for an additional year of life is actually much lower than cost-effectiveness thresholds used in a number of countries. This suggests health reforms shouldn’t overemphasize financing high-cost treatments that only moderately extend life. Evolution may have programmed us to struggle to survive – but not at any cost.
PROJECT M will take a more detailed look at health and its interplay with longer lives in its forthcoming edition, to be published August 2016