Editorial Comment
Honoring Our Dead: Creating Worth From
the Passing of Our Patients
MARC A. SILVER, MD
Oak Lawn, Illinois
For those who seek to understand it, death is a highly
creative force. The highest spiritual values of life
can originate from the thought and study of death.
dDr. Elisabeth Kubler Ross
Whether one lives in America or Canada, the familiar
story known to health care workers and public alike is
that the majority of health care dollars are consumed in
the final 6 months of life. Little has been done to impact
that statistic in the last 2 decades. Furthermore, anyone car-
ing for patients with advanced heart failure is brutally
aware that our patients easily fall within the ranks of ex-
panded health care spending at a time of diminishing re-
turns; yet, we continue, and now even have more
expensive therapies with which to explode the cost of the
patient’s demise.
Grim commentary aside, what then do we learn from the
article by Russo and colleagues in their article in this issue
of the Journal of Cardiac Failure?
1
The authors detail the cost and resource utilization of 47
Medicare beneficiaries who were assigned to the medical
management arm of the Randomized Evaluation of Me-
chanical Assistance Therapy as an Alternative in Conges-
tive Heart failure (REMATCH) trial (May 1998eJuly
2001) who expired. Three surviving patients were ex-
cluded; of the 44 included patients, only 59% had full 2
years of costing data. Summed means of cost were analyzed
in 3-month intervals in a moving backwards analysis (0e3
months, n 5 44; 21e24 months, n 5 26). As anticipated,
costs were disaggregated into various resource ‘‘buckets’’
such as in patient care, outpatient care, home care, medical
supplies, pharmacy costs, etc. Costs included everything in
the 2 years before death including costs for the patient even
before entry into the REMATCH trial. The monthly visits
mandated by the study protocol accounted for only 3.5%
of overall costs and therefore did not seemingly influence
the author’s findings.
The key findings, though of little surprise, are that the
mean total costs increased by 3-month increments ap-
proaching death, more than half the costs occurred in the
final 6 months of life, and most of the costs were for inpa-
tient care, 75% of which was related to recurrent heart fail-
ure exacerbations. Another key finding, at risk of being
overlooked, is that compared with typical infrequent refer-
rals of end-stage heart failure patients to hospice care,
nearly 25% of these 44 patients were referred and died un-
der hospice care; there was a trend to lower cost at all time
intervals for patients dying in hospice.
Although this article could easily be criticized because it
is retrospective and technically out of date, we must look at
what is new and important about this study. In one way,
truly nothing. Certainly no heart failure health care worker
will be surprised or shocked by the text, tables, or figures.
In fact, we, like the authors, make note that, if anything, the
reality is likely to be worse this very instant because the
study, now a decade old, predated some of our more expen-
sive therapies, including implantable cardioverter defibrilla-
tors and cardiac resynchronization devices. And although
guidelines might suggest that these therapies are contraindi-
cated in those patients likely to die within the ensuing year,
many are still implanted hoping to ‘‘bail out’’ the patient so
ill in our office or hospital. Guidelines are, after all, ‘‘guide-
lines.’’
If, however, we simply allow this report to validate our
current beliefs and practices, then these 44 deaths, no, the
nearly 60,000 who die annually in the United States, will
have gone in vain.
Let me suggest that the report is, after all, doing more
than chronicling the plight and trajectory of our futility
when it comes to the sickest of the sick. It is, I believe, try-
ing to allow these patients and their course to speak to us
from the grave. I believe it is saying, take note, and much
like a quality improvement project, asking us to Plan-
Do-Study, but most importantly Act.
From the Heart Failure Institute, Department of Medicine, Advocate
Christ Medical Center, Oak Lawn, Illinois.
Reprint requests: Marc A. Silver, MD, Heart Failure Institute, Advocate
Christ Medical Center, 4440 West 95th St, Suite 131 NO, Oak Lawn, IL
60453.
1071-9164/$ - see front matter
Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.cardfail.2008.07.237
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Journal of Cardiac Failure Vol. 14 No. 8 2008