Guidelines: Cost is an ethical concern

Begin difficult conversations

The 2013 Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life acknowledge cost as an ethical concern in health care. "As a nation, we've decided not to have a national conversation about how to rein in health care costs — at least not yet," says Mildred Z. Solomon, EdD, president of The Hastings Center and a member of the project working group, which developed the Guidelines.

This responsibility is falling instead on the shoulders of institutional leaders. "Chief medical officers, vice presidents for safety and quality, as well as chief financial officers can all play a leadership role in ensuring better quality care at more reasonable costs," says Solomon.

A new section of The Hastings Center Guidelines provides health system leaders with specific strategies for beginning difficult conversations about costs of care within their own institutions. "This is particularly timely, given the move to accountable care organizations and enhanced opportunities to build in greater care coordination across settings," says Solomon. "This is an example of the kind of leadership the Guidelines hope to stimulate."

The ethical goal of treating all patients equitably requires health care institutions to grapple with the moral as well as fiscal dimensions of resource allocation and health care cost. The Guidelines include a guide for hospitals and other institutions, with six strategies to encourage productive discussions that can support the development and use of a transparent policy.

"This is not to say, though, that end-of-life care is the primary driver of health care costs, nor even that better palliative care will substantially reduce costs, though it may," says Solomon. The main drivers of costs are other factors, such as the aging of the baby boomer generation, the prevalence of chronic conditions, and the prices paid for drugs, devices, and procedures.

The main reason to ensure better palliative care is not to save money, but because access to pain relief, psychosocial support, and advance care planning is something every American should be able to count on, adds Solomon. "The new Guidelines summarize the state of the art in all these areas, for both adults and children," she says. "They are a resource for all clinicians, no matter whether they work in quaternary and tertiary health care organizations, primary care, or long-term care settings."