BOGOTÁ — An old patient who dies alone in the Intensive Care Unit, unable to say goodbye to his or her family. Or a 94-year-old subjected to surgery that cannot possibly prolong his life. A child who dies crying, while calling parents who are not permitted to enter the room. These are typical situations when there is no palliative care, and real cases I have seen. They happened but never should, in any country or circumstance.
The key is simply to do things well. They say spending more money does not bring happiness – and it certainly does not mean better care for patients nearing the end of their lives. In fact doing things well costs less, not more, and that is no presumption based on theories or mathematical models. It is a firm conclusion we may draw from the results of real programs and experiments showing how earlier palliative care combined with specialist medical attention may yield a holistic response to illness that is social, sanitary and community-oriented. By considering the patient’s desires and needs, one can boost clinical efficacy and the satisfaction of patients and their families. And cut costs.
As I say, the results do not rest merely on statistical projections. After working for over four years setting up and certifying the quality of palliative care programs, the results obtained were far from dubious. There is another way to die. Fifty or so organizations in Colombia have shown this by developing excellent palliative programs with the keenness and commitment of their professionals. In two of the programs whose results we recently assessed and presented, the experience of more than 3,500 patients confirms improvements in all indicators during this terminal phase. In one program, pain was brought under control in 85% of patients and in another, 80% of patients from an initial 60% rate. Satisfaction in both programs rose to 95% and clinical efficacy, respectively to over 81% and 71.7% (when a 55% satisfaction level is considered excellent), from an initial 50% or so.
Palliative care is not resignation before defeat.
Naturally all this is achieved by providing more services more frequently, which does not however mean higher costs, because more and better attention means fewer hospital entries and shorter stays, and fewer emergencies and costly drugs. In the two, real cases, patients in the palliative programs were cared for at 25% below the costs of patients outside. The savings rose to 50% in the last month of life, thanks to a notable increase in walking and home activity. When patients are better cared for and near to home, they generate less costs for the system. In our experiences, home and ambulatory expenses increased tenfold but hospital costs dropped drastically, with total savings of 25%. I insist, this is not the cause, but the consequence of doing things well.
This is one, but evidently not the most important consequence of this care model, for that of course is the positive impact on health and quality of life, as indicators have shown. Another positive consequence is where the patient dies: the World Health Organization has proposed a 50% target of patients dying at home, which regrettably is far from being the case now in most countries. In the two programs cited, 70% of patients died at home, though the first condition of our methodology is that the patient should want to do so. In other words, nobody dies at home if they want to be in hospital.
From outside, palliative care tends to be seen as something marginal, almost residual and very distant. We believe, or want to believe, that we shall live long and with great quality of life to the end, when death suddenly takes us from this world. But the reality is otherwise. It is that we shall all die, most with chronic illnesses and 70% of us will need palliative care. If we receive this, we shall not live more (or less), but much better in the last months of our lives. Palliative care is not resignation before defeat but on the contrary, means holding onto the best quality of life until the end.
I began the article with three dramatic and real situations I have seen, and which should never happen. In contrast with them, I would cite three equally real cases that were much more promising, tender and humane. They are of three patients undergoing palliative treatments who could fulfill their wishes in the final moments of their lives. Their wishes were to return to the countryside to say goodbye to pets, seeing and hugging the children one last time, and thirdly, to eat a piece of chocolate cake. All three died as they wanted. Ultimately, that is the aim of palliative care: to put patients’ needs and expectations at the center of the care given them. It is a goal that is desirable, viable and cost-effective.
