Writing "Hospice Uncovered" for the last two years has given me a wonderful opportunity to introduce our followers to hospice. This year we have focused on introducing you to some of our team members, and we will continue to do that in coming issues. This month, however, I would like to offer some thoughts on health care reform.

All of us in health care have been consumed by the debate on health care reform. The sweeping proposals contained in both the House and Senate versions of the reform legislation have put all of us under a microscope.

As a sitting member of the National Hospice and Palliative Care Organization's Public Policy Committee, and as Chairman of the Texas New Mexico Hospice Organization's Public Policy Committee, I have had the privilege of some front line involvement in the debate. Like every sector of health care, the hospice community has worked diligently to educate Congress on the service we provide and to establish the value of our services to the health care consumer.

While the current legislation seems indefinitely stalled as a result of the Massachusetts election, the debate will continue. One of the things that evolved from the debate was a frank look at how we approach end of life care and the utilization of Medicare dollars at the end of life. The statistics are quite startling. Approximately one third of all Medicare dollars spent are spent during the last year of a beneficiary's life.

Of that amount, approximately one third is spent during the last month of life. In 2009, total Medicare spending was approximately $511 billion. It is projected that total Medicare spending will almost double by 2018 to something in the neighborhood of $926 billion. What we spend on end of life care, in the last year of life and the last month of life is staggering.

Ultimately, we have to move to an honest discussion of whether or not these dollars extend life in any meaningful way, promote a meaningful improvement in the quality of life or make a meaningful sociological or even moral contribution to our great society. This will be a delicate conversation. But, we must have the conversation.

One of our M.D. segments several months ago dealt with the subject of health care professionals having end of life discussions with patients. That article pointed out that there is probably no more difficult conversation in medicine, than one which touches the subject of the end of life. If that conversation is difficult in the context of the sanctity of the physician patient dialogue, imagine the challenge of our entire country engaging in the discussion.

The intensity of what we are likely to experience as we engage in the debate was foreshadowed by some of the "killing granny" rhetoric, the suggestion that health care would be withheld for the old and infirm. Another avenue of attack has been the suggestion that limiting the ability of anyone to access all of the tests, treatments, medications and procedures that they may want, amounts to a form of euthanasia. These profound emotions will challenge our ability to objectively discuss care at the end of life.

No generation in the history of mankind has seen more increase in knowledge than those of us who are baby boomers. One of the most spectacular areas of knowledge increase has come in medicine. The 1962 Nobel Prize in Medicine was awarded for the discovery of the molecular structure of DNA, the double helix. When I was a biology major in college in the early ‘70s, we discussed the "possibility" that the DNA double helix might someday be de-coded.

Today, we are contemplating unimaginable medical procedures, medications and treatments based on our increasing ability to "engineer" DNA. That is just one tiny example of our explosion of knowledge.

Despite all we have learned, are learning and will learn in the future, life always has been, is, and always will be, finite. Advances in knowledge might extend life, might make the end more predictable and might make the end easier. But the end will come.

The discussion must happen. No matter what happens in the current climate of health care reform, no matter what happens with the current legislation, the facts are that there are limited dollars available. And, there is extreme competition for those dollars.

Like it or not, we have to talk about the priority for how those dollars are spent. My hope is that we will continue to engage in a meaningful dialogue and that along the way, we will expand our knowledge of how to provide competent, compassionate and comforting care to those at the end of this grand journey.