This is an archived article that was published on sltrib.com in 2008, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
This article originally ran April 7, 2008, in The Salt Lake Tribune.
WEST VALLEY CITY - After raising 10 children on her own, Teresa Reyes cared for her daughter-in-law, Nicaela, when the younger woman delivered three children.
So after the older woman had her third heart attack and decided she didn't want surgery, there was little question the 81-year-old would live out her last days in her son and daughter-in-law's home.
When she's not resting, Reyes tells Nicaela stories about growing up in a Mexican village. She listens to her son read the Bible. Occasionally, she walks to the stove and sneaks palmfuls of chile spices before dinner.
She won't be going to the hospital when she has another heart attack. Explaining her decision to die at home, Reyes says in Spanish (translated by her social worker): "Who better than my children to provide for me?"
Utahns like Reyes who want to die at home are lucky: A new study released today by the Dartmouth Institute for Health Policy shows Utah provides the most conservative medical care in the nation to elderly patients in their last six months of life.
That means Utahns are less likely to spend their final weeks in the hospital, meeting with teams of doctors, undergoing invasive treatments, hooked to machines. Instead, they have a better chance than residents of Newark, Los Angeles and Denver to be in their homes or a hospice center.
That translates to Utah having the second-lowest Medicare spending on inpatient hospital care in the country.
But doctors and nurses who care for Utah's dying say more work needs to be done. That's why hospitals are adding specialists to ensure that patients know they are in control of their care and ultimately their death.
"We put a tremendous amount of energy into helping new mothers and fathers have babies. We really focus on making that beginning life experience a rich and a safe and a wonderful one," says Helen Rollins, in charge of Intermountain Healthcare's bereavement services. "We deserve to give that same high-quality of care to patients and families [of patients] who are dying."
The benefits of less care
In their 2008 Atlas of Health Care, Dartmouth researchers compared equally sick patients across the country - chronically ill Medicare patients who died between 2001 and 2005 - so Utah's young population and healthy lifestyle didn't muddy the results.
In a separate analysis for The Salt Lake Tribune, Dartmouth found Utahns receive different end-of-life care depending on their hospital.
For example, treatment is more aggressive at Dixie Regional in St. George, where Medicare patients spent nearly $3,000 in co-payments during the last two years of life and saw 23 doctors in their last six months. At Utah's most conservative hospital, American Fork, patients spent $1,000 less and saw eight fewer doctors.
Conservative care doesn't mean low quality. It's exactly the opposite, according to the report, which says the risk of dying rises with more care. More time in a hospital means more exposure to infections. The more doctors involved, the more room for medical errors.
"Hospitals are inherently dangerous," says Brent James, Intermountain Healthcare's vice president of medical research.
A matter of honesty
Dartmouth, as it has in previous reports, held up Intermountain as a model for efficiency and quality. James chiefly credits electronic medical records, which he and others at Intermountain have mined to standardize and improve treatment. He said changes also were made to intensive care units to improve communication between doctors and patients, and with families of patients who are dying, leading to greater use of hospice care.
"Using intense care in a hospital is not going to significantly prolong their life," James said of the terminally ill. "Frankly, it's a matter of honesty."
Rollins recalls one young mother who didn't want to continue kidney dialysis. She lived a year without returning to the hospital and spent that time with her children.
But too often, Rollins sees patients continuing treatment to please their doctors.
"When they think it through and get the support to understand it's their life, their decision and ultimately their death," she says, "more and more will leave ICU or never get there."
University Hospital, the state's second-largest, is ranked as more aggressive by Dartmouth.
While questioning the ranking's methodology, the U. is trying to improve end-of-life care by putting the patient - not the disease - first.
It's a paradigm shift for doctors and nurses who are trained to cure at all cost, says Stephen Bekanich, medical director of the U.'s Palliative Care Services.
Dying with dignity
The U. palliative care team, which includes Bekanich, two nurses, a chaplain and a social worker, started working two years ago with patients who have serious and life-threatening illnesses.
The team treats symptoms like pain, anxiety and depression - which can be the side effects of aggressive treatment, Bekanich says. They coordinate care from specialists, who may focus on attacking disease and not consider all of the consequences of treatment.
Palliative care can save resources by cutting down on hospitalizations and time spent in intensive care. But doctors have been skeptical, and the team is typically called in long after diagnosis, when a patient is nearing death.
Palliative care isn't a death sentence. The team helps patients understand their choices. If a patient wants heroic, aggressive care, that's what happens.
But nationally, many patients say they don't want to die in intensive care units. They would rather be home.
To explain the power of such care, Bekanich recalls a man in his 90s who was suffering from dementia and was admitted to the U. hospital with pneumonia. After meeting with Bekanich and social worker Kathie Supiano, the family decided to try another feeding tube, even though he had pulled out others, and they took him to a long-term acute care facility.
When his health worsened two days later, Bekanich and Supiano were called at 5 a.m. The family met again and decided to let the man pass.
Without the team, Bekanich believes the man would have been taken to an emergency room, given a permanent feeding tube and a ventilator and died in the ICU.
"He absolutely still would have died and it probably would have been a lot less comfortable, not nearly with as much dignity, probably not surrounded by all his family members the way he was," Bekanich said.
Last days
When death comes for Reyes, the 81-year-old hopes she will go peacefully and comfortably, without pain.
For now, Intermountain Homecare Hospice sends a nursing assistant to bathe and dress her every morning. A nurse manages her pain. A social worker prepares her for the end.
There have been times when her family thought Reyes was close to passing away. But then she would regain her strength. Nicaela Reyes, her daughter-in-law, thinks she knows why.
"She's surrounded by love."