Aggressive Medical Care at the End of Life: Does Capitated Reimbursement Encourage the Right Care for the Wrong Reason?

The quality of medical care at the end of life is receiving increased attention in both the popular press 1 and professional journals. 2,3 This interest has developed in part because of the perception that people die with ineffective, painful, expensive, and unwanted medical interventions that deprive them of their dignity, personal interactions, and family savings. This perception is not wholly unfounded. Approximately 60% of Americans die in hospitals. 4 Among the deaths of hospitalized patients in the SUPPORT study, 5 half died after receiving mechanical ventilation for more than 1 week. Many families of dying patients report that their loved ones experience moderate to severe pain during most or all of the loved ones' last few days. Many of the families of dying patients experience severe caregiving and financial burdens. 6 Efforts to improve the quality of end-of-life care through advance directives, education, and more accurate prognostic information have