September 19, 2002
Good death possible, doctor says
By JAMES HAGENGRUBER of The Gazette Staff
Montana might be a good place to live, but it's not the best place to die.
A national report released Monday gives the state mixed ratings for end-of-life care. But Montana is not alone in its mediocrity.
Most states were given grades of C, D or failure, according to the results of the year-long study by Last Acts, the nation's largest coalition of health organizations focused on death and dying issues.
The report card was developed after researchers looked at eight areas, including rate of hospice use, pain management, physician and nurse training, location of death and use of advance directives. Research shows, for example, 70 percent of Americans would like to die in their own homes. In Montana and the rest of the nation, only about one in four people actually die this way.
The report shines a light on one of the greatest failures of modern medicine: accessing a good death, said Dr. Ira Byock, principal investigator for the Life's End Institute in Missoula and author of a popular book on the topic, "Dying Well."
A century ago, cancer was a "two-week illness," and people died in their own beds, Byock said. Medicine now helps patients fight disease, but death is inevitable and it often comes with unnecessary pain and while the patient is in institutional settings.
"The entire health system, all of our expectations, is focused on prolonging life," he said. "Our health care system hasn't caught up to the new realities that has resulted from the wonderful advances of medicine."
People want to die comfortably, and in nearly all cases, this is possible, Byock said.
A variety of programs are being used across the nation, including in Billings, to make dying easier. But these programs, including hospice, continue to be ignored by many policy makers, doctors and patients, Byock said.
According to the report, less than one in five dying patients enter hospice programs, which are available to all citizens through Medicare during their final six months of life. Hospice doctors and nurses are experts in pain management and in addressing the complex emotional issues of accepting death. Hospice also provides services that allow many people to spend their final days at home.
"We can make this shift and not spend more money," Byock said. "We're already spending an inordinate amount of money on the last years of someone's life. Money's not the major barrier. Cultural avoidance is the barrier."
About 20 percent of dying Yellowstone County residents benefit from the Big Sky Hospice Program, of the Yellowstone City-County Health Dept., said Jean Forseth, the program's manager. Between 50 and 55 people are currently enrolled in the program.
More people should be using their hospice benefits and they should be accessing them earlier, Forseth said. People are allowed six months of hospice care under Medicare. The average in Yellowstone County is 14 days. This barely gives the program a chance to connect a specially trained nurse and a social worker with the patient, much less develop a comprehensive home-care plan, she said.
"People aren't able to have the benefits of hospice when it's a real short stay," Forseth said. "It leaves the family very stressed and our service very underutilized."
Trying to change this is a "terribly uphill battle," Forseth said. Patients don't want to admit the inevitable and many doctors view death as defeat, not a natural act.
Forseth said the Last Acts report card is "fairly accurate," but the results do not reflect the wide discrepancy between rural and urban Montana. Billings residents have access to hospice and palliative care programs, as well as specially trained medical professionals. In most of the state, "there is a nursing home and that's it," Forseth said.
Change will come not from physicians and politicians, but from patients, Byock said.
"The current health care system is way behind," Byock said. "We need the general public to know what's possible and demand it."
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