Forbes — There are two major contemporary issues around how care is provided at the end of life. First, there is the very real sense that patients often receive more care and more intensive care than they would actually want, if anyone had bothered to ask. Instead, horror stories – all too real – abound. Improved dialog (many would add: any dialog) should lead to end-of-life care far more aligned with the patient’s wishes.

At the same time, end-of-life care is also frequently associated with a consistent economic message: a disproportionate amount of money is spent for care at the very end of life, care that is often said to be futile. Reduce this spending, we are told, and you could save the system a lot of money.

It’s not hard to see where the tension is, especially as more care delivery organizations begin to own a sizable share of the financial risk (such as in ACO models). An at-risk organization (and its physicians, who generally share in any cost-savings) generally does better, financially, if very sick patients select hospice rather than pursue aggressive treatments.

The key question – as Lisa Rosenbaum insightfully suggested on Twitter – is how to ensure that thoughtful conversations with patients (through the process of “shared decision-making”) do not become a mechanism for consistently nudging patients towards less care.

Real the full article from Forbes.