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It Might Be Lawful, But is it Ethical 7th National Congress on End of Life Issues Southport 4th November 2008 The Co

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It Might Be Lawful, But is it Ethical 7th National Congress on End of Life Issues Southport 4th November 2008 The Co

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    1. It Might Be Lawful, But is it Ethical? 7th National Congress on End of Life Issues Southport – 4th November 2008 The Cost of Dying Steve Warburton Director of Finance & Business Services Aintree University Hospitals N.H.S. Foundation Trust

    2. COST OF DYING - INTRODUCTION Impact of Age on Healthcare Expenditure Cost of Care at End of Life Q.A.L.Y.S. Implications for Services/Patients Conclusions

    3. IMAPCT OF AGE ON HEALTHCARE EXPENDITURE Pressures of Ageing Increase in Longevity U.K. Studies : Abel-Smith and Titmus 1956 International Evidence : Demographic Structure = Non Significant Variable

    4. PRESSURE OF DYING Lubitz (1984) - U.S. : 6% of Medicare recipients account for 28% expenditure Levinsky (2001) – decline of expenditure in last year of life Netherlands – costs increased by 170% moving from second to last year of life Zweifel et al (1999) – age is insignificant in determining expenditure in last 2 years of life but proximity to death is significant

    5. RECENT U.K. EVIDENCE Seshamani and Gray (2004) – Oxfordshire Study Longitudinal Study – people aged 65 and over in 1970 – death records to 1999 Proximity to death key variable rather than age per se Years 13 to 1 prior to death all increased likelihood of being in hospital and higher costs once admitted. Effect of proximity to death - 5 years prior to death

    6. COST OF CARE AT END OF LIFE Quality ? Leave Alone ? ? Leave Alone Spend ? Palliative Care ? End of Life spend more

    7. SPENDING ON END OF LIFE CARE Proportion of spending on care in last year of life remained stable Impact of age and functional status Impact of spending on morbidity Impact of hospice usage

    8. BARRIERS TO QUALITY END OF LIFE CARE System orientated towards acute care Payment systems do not support co-ordinated care Hospice payments reflect historic care patterns Organisational arrangements and use of Hospice care

    9. HOW TO MEASURE QUALITY OF LIFE Ethical Resource Allocations - Utilitarianism Cost Benefit Analysis Quality Adjusted Life Years (Q.A.L.Y.) 1 Year of Quality Life = 1 Q.A.L.Y.

    10. COST PER Q.A.L.Y. OF HEALTHCARE INTERVENTIONS Ł/Q.A.L.Y. 1990 price Cholesterol Testing & Diet Therapy 220 Pacemaker implantation 1,100 Hip replacement 1,180 Kidney transplant 4,710 Hospital haemodialysis 21,970 Neurosurgical intervention malignant 107,780 intracranial tumour Erythropoietin treatment for anaemia in 126,290 dialysis patients (no increase in survival)

    11. Q.A.L.Y. Increasingly used by N.I.C.E. to assess treatment Threshold < Ł20,000 per Q.A.L.Y. Do not take account of personal response to treatment Do not take account of personal preferences Inadequate weight to emotional and mental health issues

    12. IMPLICATIONS FOR SERVICES Health costs at end of life are high Retrospective assessment of treatments Hospice care – a cheap alternative? Poor study design – limit to findings Kane (1984) – no significant cost savings for hospice patients

    13. UNNECESSARY INTERVENTIONS Reduce “futile” care to save money Studies from U.S./Canada ? Validity D.N.R. Orders for Cancer Patient Chemotherapy – non small cell lung cancer

    14. CONCLUSIONS Hard to reduce Ł on patients who die Palliative care at Aintree - Ł380 a day Not less care – different care High quality end of life care is not cheap Need to spend more if we are to improve services

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