Geography plays a part in quality of a person's death
By TAMARA KOEHLER
Scripps Howard News Service
Where you live affects how well you die.
The elderly in Oregon have a wealth of services, including home-style residential treatment centers. As a result, they are less likely to die in a hospital intensive care unit - a place intended to provide the life-saving power of medicine rather than a serene and peaceful death.
There's a reason for that. Oregon takes 50.4 percent of its money for long-term medical care and spends it to treat patients at home and home-like settings.
By contrast, the elderly of Mississippi are more likely to experience their last days in a hospital or nursing home. This rural state spends only 4.2 percent of its long-term health care budget to assist patients in a home environment.
Recent studies mapping the way Americans die show that differences among states determine:
-- The kind of medical treatments given to seriously ill patients.
-- Whether an elderly patient dies in a nursing facility, a hospital intensive care unit, at home alone or in a home-like setting supported by community services.
-- Whether a patient's wishes - such as a "do not resuscitate" request - have legal backing.
The disparities derive from a variety of social and medical factors as well as state budget policies. How much patients and doctors know about available treatments and pain management will affect decisions about where the terminally ill go for care. So will the availability of home care services, hospices, hospitals and nursing homes. Clearly, though, state legislators determine the direction of care when they vote on how public money is to be spent on long-term care for the terminally ill and elderly.
States like California and Oregon have pursued fiscal policies that encourage innovation, including a push toward more home and community services. California spends 30 percent of its long-term health care budget on such things.
By comparison, Tennessee spends a far smaller portion, 5.2 percent. Yet Tennessee has the second-highest demand for such services based on factors such as how many elderly live in the state and how many have severe disabilities, according to statistics compiled by the federal Administration on Aging (AOA).
States with an oversupply of hospital beds and nursing homes tend to send dying patients to those facilities first and more frequently than states with fewer nursing home facilities and hospitals, reports a major study of disparity in care called the 1998 Dartmouth Atlas of Health Care.
"Where dying patients end up is a factor of physician preferences, availability of hospital beds and intensive care units," said Dr. John E. Wennberg, a principal author of the Atlas and professor of medicine at the Dartmouth Medical School in Hanover, N.H.
"I don't believe Americans would prefer to die in a hospital ICU, but in many cities in the United States, they do."
The Dartmouth study found that in some states such as Tennessee, Alabama and Texas, roughly half of all Medicare patients died in hospitals, compared with only 20 percent in other states such as New Mexico, Arizona and Colorado.
In California, the rate of hospital deaths varied dramatically from county to county. In Ventura County, just north of Los Angeles, 30 to 35 percent of Medicare patients died in hospitals in 1995, according to the Atlas. In Northern California counties, about 20 percent of Medicare patients die in hospitals.
Even in retirement communities, the number of days spent in hospitals and their intensive care units varied widely. The Dartmouth study found that Medicare patients living in St. Petersburg, Fla., spent nine times as long in the hospital (4.9 days) as their elderly counterparts in Sun City, Ariz. (0.5). Both cities are retirement communities.
The way Medicare pays for treatment also varies widely among states and counties. Average costs to Medicare in the last six months of life vary from less than $7,000 to more than $16,000.
That's not to say that you get better care where more money is spent. The Dartmouth authors conclude that everyone ends up with fewer "quality of life" benefits. No matter the amount spent from place to place, the Medicare dollars come out of a common pot.
In a statement contained in The 1998 Budget Resolution, the U.S. Senate recognized that while "all Americans pay the same payroll tax of 2.9 percent to the Medicare trust funds and they deserve the same choices and services regardless of where they retire," some regions "receive 2.5 times more in Medicare reimbursements than others."
As the aging population has grown, a demand has expanded for improved residential care and support services outside the hospital.
For years, the nursing home had been the only alternative outside a hospital. But along with the new demand has come an increased recognition of the varying needs of the dying. Some need round-the-clock help eating, dressing and bathing but only minimal medical treatment such as oxygen or catheters. Others need high levels of skilled nursing and access to life-sustaining medical machines.
Enter the assisted-living facility, a blend of housing, personalized support services and health care, an alternative found in some states to dramatically improve the quality of life at the end. But as with other varying standards of medical treatment, states are unevenly providing regulation or funding for assisted-living facilities. As a result, residents of one state are offered a lower-quality facility than those in other states, according to a 1998 congressional study by the U.S. General Accounting Office.
In Arkansas and Mississippi, for instance, there are no regulations or funding for programs offering assisted-living services. In Oregon, state legislators have provided both standards and money. In Maryland, the government funds assisted-living facilities but the standards for living conditions are much lower than Oregon's.
Oregon law requires that assisted-living residents have access to a private room and bath. The operators have to demonstrate they will meet the standards before they open for business.
By contrast, Maryland allows two people to share 120-square-foot rooms (10 feet by 12) with one dresser. Four people share a toilet, and eight share a shower and telephone.
Twelve states specifically provide assisted living for the elderly using state and federal dollars. But these payments don't cover room and board. Those who want to live in these facilities must either pay out of their own pockets, use up Social Security payments or, if they're lucky, tap into extra state aid such as Oregon provides.
Even when patients have carefully prepared written instructions for their own treatment at life's end, state laws will affect how closely the documents are followed.
The language of living wills differs among states and can be overly broad and vague. The National Conference of State Legislatures cites the use of imprecise wording such as "heroic measures" and "terminally ill" in some states.
Most states have separate laws for living wills and durable power of attorney, causing confusion among the public. Witnessing requirements vary as do the circumstances in which such written directives may apply. For instance, regulations over the removal of feeding and hydration tubes vary among states.
(Tamara Koehler is a reporter for the Ventura County Star in California.)