Rationing, Aggressive Care, and Wishes of the Dying.

We're starting to see regional papers and publications address the issue of rationing and end of life care costs with factual reporting and more balance than was published during the August "death panel" heat wave. Some excellent reporting is coming from these publications. This week Duane Schrag, for Salina.com, reports on costs and other issues surrounding end of life care. Regarding doctors, he writes:

"You're trained that disease is your enemy," says Dr. Kevin Norris. "You're supposed to create solutions so your patient doesn't die."

But that goal, which also happens to reinforce living creatures' powerful instinct to survive, often leads patients, their families and their doctors to avoid the inevitable.

"They want everything done until there is nothing left to do any more," said Norris, medical director at the Kaye Pogue Hospice Center, 730 Holly Lane. "It costs a lot of money."

And worse.

"(Doctors) may have every good intention, but the intervention may become an actual source of suffering," says Dr. Mark Wiles, medical director of Hospice Care of Kansas, 200 S. Santa Fe. "I don't think we're well-trained in medical school for end-of-life issues. Death is often seen as a failure."

The consequence is that medical dollars are spent most intensely as a patient nears the end of their life. Medicare data show that more than a fourth -- 27 percent -- of all Medicare costs are incurred in the last year of life.

And yet, he notes, aggressive care is seldom what the dying want:

Allegre said that what many patients want is to live their final days in peace.

"They want their pain controlled, they don't want the dying process prolonged, they want to be at home when they die, they don't want to be a burden on their families," Allegre said. "If you get into this medical vortex of ever more aggressive medical care, you miss out on all those things."

About three of four Americans die in a hospital or nursing home, she said; surveys suggest 90 percent would rather die at home.

About rationing and cost-savings, Schrag writes:

So why does health care cost twice as much in some places?

"The additional utilization in high-spending regions is largely devoted to discretionary services that have previously been demonstrated to be associated with the local supply of physicians and hospital resources," the study said. "These include the frequency and type of evaluation and management services provided by physicians, the use of specialist consultations, the frequency of diagnostic tests and minor procedures, and the likelihood of treating patients with chronic disease in the inpatient or intensive care unit setting."

In short, many Americans are paying for wasted medicine.

Who does the rationing?

But talk of addressing that can easily give rise to accusations of rationing.