'Hopeless' patients become focus of controversy.

Life support accounts for big part of total costs

Right now in Los Angeles County hospitals, there are dozens of people hooked to life support equipment who would probably choose to die if they still had the power of conscious choice. But they don't, and that represents one of the most perplexing and emotionally charged issues in the health care industry.

There is no way to measure the cost of life support for patients who have no hope of recovery, mainly because opinions about what constitutes a "hopeless" patient are so varied.

Some experts estimate that as much as 25 percent of the nation's overall health care expenditures go toward care for "hopeless" patients, because life support usually involves long-term treatment in the most expensive possible settings - hospital intensive care units.

Beyond the economic concerns, there are profound moral issues involved with end-of-life decisions. A great deal of the emotional and monetary cost might be eliminated if more people filled out advance directives specifying their wishes in the event of a loss of the power to choose.

Federal law requires hospitals to provide patients with information about advance directives upon admission. However, studies show that only a very small percentage of hospital patients have such directives in their medical files.

Advance directives come in two forms: living wills, which state the kind of medical care to be given in the event of incapacity to choose, and health care powers of attorney, which specify a friend or family member who will be given the power to make choices for an unconscious patient.

Scarcity of directives

According to a 1993 study by California Medical Review Inc., a San Francisco-based nonprofit organization that measures quality of care for Medicare patients in the state, only 3 percent of California fee-for-service Medicare patients over 65 had any kind of advance directive in their medical files.

Leslie Baker, who helped perform the advance directive study and is currently working on a similar project involving 35 hospitals in Southern California, said few hospitals have educational or outreach programs to encourage people to create advance directives. Although the current study is not yet complete, she said she expects once again to find that fewer than 5 percent of Medicare patients in the surveyed hospitals have directives in their files.

Analysts said there is a reason that hospitals and managed care plans do little to encourage people to fill out documents specifying whether extraordinary means should be taken to keep them alive.

"Hospitals, and health maintenance organizations in particular, are very, very wary about the perception of a conflict of interest," said Alexander Capron, a professor of law and medicine at the University of Southern California.

Capron and other experts on medical ethics agreed that an adversarial relationship has developed in recent years between health care providers and consumers. If people perceive that doctors and hospitals want them to fill out advance directives simply to save money, they will avoid doing it.

By the same token, family members of patients on life support are often reluctant to shut the systems off because they think the only reason doctors are counseling them to do so is that they want to save money, analysts said.

Ethnic influences

L.A. County's ethnic diversity apparently is a major factor contributing to this region's dearth of advance directives. Non-white Americans are more reluctant to make health care decisions in advance, according to a 1995 study led by Dr. Leslie Blackhall, a fellow with USC's Pacific Center for Health Policy and Ethics.

Blackhall's study found that 65 percent of elderly European Americans surveyed believe that patients should make their own decisions about the use of life support; 60 percent of African Americans concurred, while only 41 percent of Mexican Americans and 28 percent of Korean Americans thought so.

Despite the general lack of outreach on advance directives by health care providers, a cooperative nonprofit group called the Bioethics Education Network is being formed by St. John's Hospital and Health Center in Santa Monica, Santa Monica-UCLA Medical Center and the UCLA Medical Center. The network's goal is to serve an educational function by counseling people in the community on end-of-life issues, holding seminars for churches and synagogues, community groups, and even businesses.

St. John's and Loyola Marymount University already run a similar program called the Bioethics Institute, which counsels physicians, patients and family members at St. John's on end-of-life issues and encourages people to draw up advance directives. David Blake, the institute's director, said not only patients but doctors need to be educated on the subject.

Blake has never compiled figures to determine whether his institute, funded by the hospital and Loyola Marymount, has saved money by cutting down on life support time - mainly because of the perception of a conflict of interest that might result from such a finding.

"It just seems common-sensical that, if people are not afraid or in denial about death, there's going to be more of the right kind of treatment at the end of life, and that's going to lead to significant cost savings," Blake said.