Healthcare Matters

Statistics indicate that half of us have had a friend or relative suffer from a terminal illness or coma in the last five years and that the issue of withholding life sustaining treatment has come up in our conversation. If we recognize a social benefit in educating our children on reproductive matters, then efforts to educate the general public about end-of-life issues–including symptoms to expect and palliative care options– are equally necessary.

A policy to reimburse physicians who provide end-of-life counseling was to be enacted as part of the Affordable Care Act. The policy became known as “advance care planning.” Understandably, this provision of the Act had widespread bipartisan support. Enter Sarah Palin. She successfully morphed talk of reimbursing physicians who would counsel patients about end of life issues into rhetoric about the existence of government “death panels.” And that was that. So much for congressional courage.

Medicare pays a big percentage of its total per patient reimbursements in the last year of life (25%-33%). That’s a big number, so it must be included in adult conversations about healthcare reform. And while the public’s perception of end of life spending may be even greater than it actually is, a better question to consider, regardless of expense considerations, is whether patients are even getting the care they want.

No surprisingly, end of life Medicare spending tilts toward inpatient, acute care and away from all other forms, including hospice care, palliative drugs and other therapies. However, not only do many patients say they are not in favor of heroic measures at the end of their life, but medical evidence indicates that such measures are often counter productive. Surveys of Medicare beneficiaries indicate that most want to spend their last days at home without using mechanical ventilation and life-prolonging therapies that decrease their quality of life –and they do better! These findings suggest a clear disconnect between the desires of most patients for a more peaceful death at home and the gravity of a system that pulls most Medicare beneficiaries to acute-care hospitals during their last days of life.

Doctors don’t die like the rest of us. Perhaps we ought to pay closer attention to how they handle the end of their lives? After all, I think that most of us would concede that they’re better informed than we are; that they have access to all the best thinking, care and drugs they want. A physician, Ken Murray wrote: “What’s unusual is not how much treatment doctors get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They go gently. They don’t over-treat themselves.” No surprisingly, most physicians die peacefully at home. And according to most doctors, making sure that happens for their patients isn’t that hard to do, but it still happens less than 20% of the time for the rest of us who want the same thing!

Obviously, we’ve got an education problem. Ironically, if Americans don’t want death panels, but want a system that holds sacred the freedom of patients to make their own end of life decisions with the help of their doctors, then we must begin to train and compensate physicians for participating in this essential decision-making process.

Today really is National Healthcare Decisions Day. National Healthcare Decisions Day is a 5 year old/strong initiative to encourage us to document our wishes regarding our end-of-life healthcare preferences –and for providers to learn to respect those wishes, whatever they may be.

—Tom Finn