A version of this op-ed was published on April 12, 2011 in USA Today.
“Would you like to discuss your end-of-life plans today?”
It’s a question that I ask my patients, although not as often as I would like. Talking about death may be uncomfortable, but it’s a conversation that needs to happen more often.
We can never know for sure when health disaster will strike, robbing us of the ability to make our own medical decisions. More than 40% of elderly Americans will need to make crucial medical decisions before death, yet most of them will lack the decision-making capacity to do so at the time.
This places significant stress on family members, who then must make life or death health decisions on behalf of the patient. When the Annals of Internal Medicine looked at the impact of surrogate decision making, words like “intense,” “painful,” “traumatic,” and “overwhelming” were used to describe the experience for loved ones. Emotions tended to be less negative had they been aware of the patient’s end-of-life preferences beforehand.
The reality in primary care is that these important conversations are too often skipped, since they take time, do not conveniently fit into the 15- or 20-minute appointments typically allotted to patients, and are not billable. Those are partly reasons why, despite the fact that 9 out of every 10 patients want to discuss end-of-life care with their physicians, more than 60% of dying patients did not recall having such discussions with their doctor.
On January 1st this year, a Medicare proposal sought to encourage these conversations by including it during the annual “wellness visit” provided to beneficiaries. That would have been an ideal opportunity to ask whether patients wanted to discuss their end-of-life plans, alongside other preventive measures such as screening for cancer, diabetes, or depression. If the time wasn’t right, patients could simply say, “No, thanks,” and move on. But I find that most are willing to engage in a thoughtful discussion of their end-of-life wishes in a comfortable, routine setting, rather than being forced to do so in a hospital emergency room or intensive care unit.
Days later, however, the Obama administration abruptly reversed course and revised the language to remove all end-of-life references, a move the New York Times said was due to “clear political concerns.” House Speaker John Boehner called the Medicare provision a step “down a treacherous path toward government-encouraged euthanasia.” And the Washington Post’s Charles Krauthammer called Medicare reimbursements for end-of-life planning a “possible first slippery step on the road to state-mandated late-life rationing.”
Opponents often link end-of-life planning to an insidious attempt to pare down health costs. While it’s true that a disproportionate share of Medicare dollars is spent during the last year of life, up to 30% of those expenses do not benefit patients. Incentivizing doctors to take the time and clarify one’s end-of-life wishes can help reduce potentially harmful treatments. Indeed, according to a 2008 Archives of Internal Medicine study, patients who had end-of-life plans fared better when compared to those who didn’t, as they received less aggressive care and had a better quality of life near death.
Rationing care, cost control, and the fictitious concept of government-sponsored “death panels” are never brought up during my end-of-life conversations with patients. Instead, many find it an empowering discussion that promotes their autonomy and helps ensure that they receive the care they want.
Patients should be given more opportunities to express their end-of-life wishes. By allowing politics to influence their decision, Medicare has denied doctors chances to engage patients in this important conversation.