Medical care is becoming increasingly expensive, and this is a fact that can no longer be neglected or ignored in our country. But even as costs rise, parallelly, there is a rising demand for various healthcare services given the ageing population and the plethora of chronic diseases. At this juncture, there is a critical need both for integrated palliative care (PC) services and a need to understand the economics of PC.
Economics of PC
There is no doubt that PC intervention improves the quality of life (QoL) of patients, family and their caregivers right through the disease trajectory, with end-of-life care (EOC) and further into the bereavement period. However, it is imperative to analyse the cost-effectiveness of PC given the length of the trajectory compared to the initial phase of general medical/surgical care. However, the economics work in favour of PC: palliative interventions are both beneficial and economical, and therefore justifiable to the patient and/or family, considering all of the elements provided.
This can be understood with a detailed look at the elements of PC care. The mainstay of PC therapy is supportive, symptom control and the avoidance of unnecessary interventions or devices that could prolong the suffering with no possibility of cure. PC also focuses primarily on symptom control, and hence, only essential medicines are used. Medical/surgical intervention decisions are made only if the quality of life of the patient and day-to-day activities of daily living can be improved. Compassionate care and open communication with the patient/family/caregivers help make meaningful decisions, taking into consideration various facets of care including financial aspects. This means that the patient or family will not have to grapple with or be caught unawares by huge bills, while however, understanding the importance of continuing essential care. Palliative care also helps give patients and their families a voice: machines, peripherals and medications which may not contribute to cure or improvement in QOL may be continued either because of there is no PC team within the hospital or there is a lack of standard operating procedures (SOPs) to wean a patient to PC and/or supportive care; this can be exacerbated by a hospital’s own economic considerations and lack of awareness among patients.
High touch, low tech
Palliative care therefore, is a ‘High Touch, Low Tech’ style of management. Take cancer as an example. Standard therapeutics such as surgery, chemotherapy, radiation and targeted therapies can help save many lives. But in cases where the patient becomes non responsive to treatment the patient, and the family must be guided towards supportive care, to live the rest of their lives with pain management, and to be able to encounter death with dignity.
In India however, recognition of this continues to be low amongst cancer specialists. The same scenario extends to other chronic disease states such as post-Covid frequent respiratory disorders with on and off hospitalisation.
Diabetic wound management is another area where care from home could prevent deterioration that leads to limb amputations. Chronic kidney disease, chronic neurological disorders (Alzheimer’s/ Parkinson’s and other dementia states) require long-term supportive care but not necessarily frequent hospital admissions if good palliative teams are in charge. Tethering patient to various life-supportive devices and lines could be both expensive, and, in some cases, futile.
Hospital costs
Research has shown that increasing palliative care capacity could bring down costs for hospitalised adults with serious and complex illnesses. This includes decreasing the number of days spent in Intensive Care Units (ICUs) and thereby charges and medicine costs, through discussions on essential medicines and prescribing lower-priced brands. A PC team will also discuss, upfront, the financial capabilities of the family, whether or not there is insurance available, the cost of follow-ups and continuity of care during the EOC phase, family bereavement and counselling. Such discussions help the patient and family become aware of the exact situation at hand and help minimise costs from the very early stages of treatment onwards.
Reducing stress
When patients do not have adequate information about or a clear understanding of the treatment outcome of an incurable chronic disease, they may undergo multiple investigations and procedures that are not warranted, which adds not just to their financial burden but also causes psychological stress, worsening the original illness.
If rising costs do not allow a patient to be managed at a hospital, alternatives such as assisted living and senior care facilities should be considered. These institutions too, must ensure that they integrate PC physicians when it comes to the care plans of residents.
Questions remain
There are many questions that continue to remain unanswered in the healthcare scenario in India. Who bears the costs and who takes care of pain of patients? Why is the quality of life of the patient and family not prioritised? Who handles end-of-life care processes? Why are patients not being handheld from the start of a disease until the end? Why are we not providing death with dignity for so many of our patients? Nature taught us through the painful lesson of the COVID-19 pandemic that supportive care and integration of various healthcare disciplines can lead to wonders. It is time now to integrate palliative care within all domains of healthcare, to provide all patients with compassionate care through their medical journeys.
(Dr. Republica Sridhar is founder and managing trustee, RMD Group of Hospitals. rmdacademyforhealth2019@gmail.com)