The vigorous debate over healthcare reform has involved a lot of discussion about an issue we oncologists deal with regularly: end-of-life care.
The vigorous debate over healthcare reform has involved a lot of discussion about an issue we oncologists deal with regularly: end-of-life care. The topic jumped to the forefront of the nation’s conscience following a legislative proposal that would require Medicare to reimburse physicians for “Advanced Care Planning Consultations.” This would involve meeting with patients at their request to discuss common end-of-life concerns, such as living wills, do-not-resuscitate orders, artificial nutrition, hydration, blood transfusions, and other palliative care measures.
This is not a new concept; in 1990, President George H. W. Bush signed the Patient Self-Determination Act, which required healthcare organizations to inform Medicare patients of their right to complete an advance directive and to document any end-of-life directives in patients’ medical records. The 2003 Medicare Prescription Drug, Improvement, and Modernization Act specifically authorized coverage for advising terminally ill patients “regarding advanced care planning.”
Nobody made a fuss back then. This time around, however, frightening terms like “death panels” and “health care rationing” are being bandied about, and people are worrying about doctors “pulling the plug on grandma.” Regardless of your position on the direction Congress should take with health reform, you must admit this lack of understanding about the purpose of “end-of-life” discussions is discouraging.
Physicians have never had an easy time broaching this sensitive subject with patients—and many physicians never do. According to a Harvard Medical School study published this spring in the Archives of Internal Medicine, nearly half of terminally ill patients said they had not discussed end-of-life concerns with their physicians. Other recent studies placed the percentage closer to 30%.
Yet, as oncologists, we know how important this discussion can be for patients. While some patients want to exhaust every possible treatment option no matter how futile, others choose another route. On learning chemotherapy will no longer benefit them, they stop treatment and spend their remaining days making peace with death. Patients who engage in end-of-life discussions tend to enroll in hospice care sooner, receive fewer aggressive medical interventions before death, and experience better quality of life in their remaining days. They are also less likely to die in an Intensive Care Unit, something many patients expressly say they hope to avoid. As a byproduct of this dignity-saving measure, the money saved can be used to fund treatment for patients who need and/or desire it.
Trust is a vital component of the relationship between oncologist and patient. It does not help if our patients, at one of the most vulnerable times of their lives, are fearful that “end-of-life discussion” is a euphemism for “pulling the plug” rather than a sincere effort to ensure that, when the time comes, they are allowed to die in the manner they choose. Guaranteeing coverage for these conversations means that patients who want them can have them and physicians will be compensated for taking the much needed time to give this important issue the attention it deserves.