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End-of-life Discussions are Already in Medicare Program
www.star-telegram.com
August 24, 2009
"Death panel" fear-mongers are too late.
The much-maligned end-of-life counseling to encourage advance directives has been paid for by Medicare since 2005. People aged 65 are entitled to a "Welcome to Medicare" exam that includes a physical and mental assessment, counseling on how Medicare works and what it covers, tips on how to prevent falls at home and the now-controversial counseling. The government would pay for this up to one year after Medicare enrollment.
The end-of-life discussion, previously optional, became mandatory Jan. 1. Among the mandate’s biggest champions were Republicans who now disavow their involvement.
The proposed healthcare overhaul legislation would pay for the end-of-life discussion between physician and patient every five years. This is milder than legislation sponsored by Sen. Johnny Isakson, R-Ga., that would have required Medicare patients to have a living will.
What was once a nonpartisan issue is now anything but.
The death-panel rhetoric has it all wrong: government isn’t making end-of-life decisions, it’s facilitating discussion between physician and patient.
There’s danger that this misguided debate will give advance directives a wholly undeserved bad name.
Texas has been a leader on this issue. In 1999, then-Gov. George W. Bush signed landmark legislation providing a framework for resolving disagreements about treatment when caregivers consider it medically futile but patients or their families do not want to give up hope. At the time, the law was considered the best in the nation and a model for other states.
That legislation — the Texas Advance Directives Act (TADA) — was the product of consensus by the Texas Advance Directives Coalition, composed of about two dozen diverse stakeholder groups such as powerful medical interests, left-leaning disability rights advocates and conservative right-to-life organizations.
The law covered living wills; medical power of attorney; and out-of-hospital do-not-resuscitate orders. The coalition tried to improve TADA in 2007; the hope is that the current debate doesn’t derail future efforts.
About 80 percent of the 150,000 deaths annually in Texas occur in a hospital or nursing home, and 80 percent of those involve a decision to withhold or withdraw one or more medical interventions to let the patient to die in dignity and peace, said Dr. Robert Fine, director of the Office of Clinical Ethics and Palliative Care for the Baylor Health System.
Ideally, the advance-directives discussion should take place in the office of a trusted physician, but it can be time-consuming to get it right. Patients need to be asked for detailed decisions about ventilators, feeding tubes and defibrillation to restart stopped hearts.
According to a survey in the New England Journal of Medicine, more than half of respondents would refuse such invasive measures if they were in a coma, even if there were a chance for recovery. The refusal rose to about 80 percent if they were in a persistent vegetative state. Following these wishes would make a huge dent in the 25 percent of U.S. healthcare dollars spent in the last year of life of the 1 percent of us who die each year.
A typical consultation can take about 40 minutes. Not compensating physicians for this amounts to charity care. It makes sense to reimburse physicians whenever the patient is ready to do this, not just at age 65.
Advance directives can be as important as preparing a will. You dictate what happens to you, and you lessen the emotional and perhaps the financial burden on the loved ones you leave behind.
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