Remember “death panels?” In the summer of 2009, in the midst of the debate about the Affordable Care Act, aka Obamacare, a small item in the legislation allowing Medicare to reimburse physicians for end-of-life conversations with patients unleashed a tsunami of criticism. Opponents charged that so-called “death panels” – anonymous Washington bureaucrats – would be making decisions about rationing health care and ultimately deciding who would live and who would die. As foolish as that charge was, the Obama administration choose not to fight the opposition and the payment proposal was dropped.
Now, the Centers for Medicare and Medicaid Services has announced a new policy. Beginning January 1, 2016, the government will reimburse voluntary end-of-life conversations that Medicare physicians have with their patients.
We asked Stanford’s VJ Periyakoil, MD, a nationally recognized leader in palliative care, for comment, and she said, “Medicare’s proposal to reimburse doctors to have a conversation with the patient about their values and preferences for care is a quantum leap forward towards the lofty goal of improving quality of care for all Americans at the end-of-life.” But she emphasized that this is just one part of the solution:
Advance care planning is not an event but a process. The key is having conversations in plural, over time as patients’ goals of care change as their illness progresses.
Early in the illness, most patients prefer to have a trial of high-intensity treatments including life support, and this is a very reasonable thing to do. However, there is a tipping point in the illness trajectory where we go from prolonging life with quality to prolonging the dying process. Beyond this tipping point, most patients, if given a choice, prefer to die gently and naturally at home minimizing the burden to their loved ones. But in order for this to happen, we need doctors who are well trained and highly skilled at conducting end-of-life conversations with their patients. We need to ensure that patients and their proxy decision makers are well supported to make end of life decisions. Finally, it takes significant support of both the patient and caregiver by a skilled team of clinicians to ensure a gentle and peaceful death at home.
Unless we have all these components in place, we can’t expect to see major and sustained improvements in end-of-life care.
Previously: “Everybody dies – just discuss it and agree on what you want”, In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues, A call to “improve quality and honor individual preferences at the end of life”, Study: Doctors would choose less aggressive end-of-life care for themselves and On a mission to transform end-of-life care
Photo by National Cancer Institute