Editorial: Better planning for end of life

Under a proposal, Medicare would reimburse medical professionals for holding formal end-of-life discussions with patients and their families. This prudent and proper change will help ensure that difficult but necessary discussions take place. Above, Janice Ryan signs a living will and health care proxy form with her husband, Richard, in Dundee, N.Y. New York Times
Under a proposal, Medicare would reimburse medical professionals for holding formal end-of-life discussions with patients and their families. This prudent and proper change will help ensure that difficult but necessary discussions take place. Above, Janice Ryan signs a living will and health care proxy form with her husband, Richard, in Dundee, N.Y.New York Times
Published July 10 2015

While most medical care focuses on keeping people healthy and alive, a proposed change in Medicare payments also recognizes the importance of assuring a humane death. For the first time, Medicare would reimburse medical professionals for holding formal end-of-life discussions with patients and their families. This prudent and proper change will help ensure that those difficult but necessary discussions take place.

Society's push for advance directives and health care surrogates parallels modern medicine's ability to extend the lives of very sick people. Ventilators, feeding tubes, drug therapies and complex surgeries often present difficult trade-offs with no clear answers. Patients are not always competent to make choices and family rifts can develop just when love and connection matter most. Preparing for this difficult passage under the informed guidance of a medical professional is critically important.

Medicare serves 55 million older and disabled people, including about 80 percent of Americans who die each year. The proposed rule would pay doctors, nurse practitioners and physician assistants to help patients sort through treatment options and fill out advance directive forms. Payment rates are not yet set, but Medicare's chief medical officer announced that multiple consultations would be covered because circumstances change and some families need extra assistance.

The American Medical Association, AARP and other advocacy groups have long lobbied for Medicare to reimburse for end-of-life planning, but fear and demagoguery has helped keep it on the back burner until now. Ex-Alaska Gov. Sarah Palin — trying to build on her failed vice presidential bid — accused President Barack Obama of supporting "death panels'' in 2009, when an early version of the Affordable Care Act included a similar end-of-life benefit. The National Right to Life Committee worries that end-of-life discussions will pressure families into forgoing life-saving treatments so that Medicare can save money. That is not the case.

End-of-life decisions unquestionably have a large impact on the federal budget. Over the next 35 years, the population of people over 65 will double and the number over 80 will triple. About one-quarter of Medicare dollars cover treatment for people during the last year of their life, including heroic measures that some patients neither understand nor desire. Advance directives can significantly lower what Medicare spends on end-of-life care, but that is not the point of empowering patients to participate more fully in their final days. Doctors have nothing to gain personally by steering patients to less expensive choices like hospice. If anything, Medicare data suggest that last-ditch efforts to prolong life remain a strong ethic in the medical profession. Heroic measures sometimes do succeed.

A 2013 study by Dr. Joan Teno published in the Journal of the American Medical Association described intriguing nuances in the care of dying Medicare patients: The percentage of patients who die in hospitals is dropping, but the percentage of those who die in intensive care units is rising. More than 40 percent of Medicare patients die under hospice care, but one-quarter of those die within three days of signing up — which suggests that people are often shuffled between health care providers in their last days.

Some physicians already weave end-of-life conversations into regular treatment, but elevating end-of-life planning to a reimbursable service will expand support for people who are facing profound loss. Effective advance planning requires more than checking off boxes on a living will. People need to explore their fears and figure out how they want to live. Loved ones must process loss. The medical profession still has much to learn about helping patients and families reach humane conclusions. Paying for formal discussions is a fine place to start.

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