Amid all the hoopla over “death panels” in 2009, it was common sense that ended up buried, as a provision to pay Medicare providers for introducing conversations about end-of-life medical care was removed from the Affordable Care Act.
Fortunately, health care providers haven’t given up on this compassionate exercise, because the most nightmarish scenarios occur when patients haven’t made clear their wishes to doctors or loved ones.
The point of advanced care directives is to let the patients decide what course of care they want when they are of sound mind.
Unfortunately, family members are often left to guess and sometimes they don’t agree. Plus, some doctors are reluctant to candidly lay out the chances of survival, or their training to save patients at all costs kicks in, regardless of the odds.
Providence Sacred Heart Medical Center provides a fine example of a thoughtful way to handle the issue. It balances the efforts to tap all of medical technology to save seriously ill patients with “giving that person a life that has quality and comfort in the way they define,” as Dr. Lisa Stiller told The Spokesman-Review. She leads the program at Sacred Heart.
Having an end-of-life plan removes the agony of uncertainty. Providence endorses the “Five Wishes” booklet, which encourages people to write down and notarize their wishes for how far they want doctors to go. Attorneys specializing in elder law can also help people map out a plan and take their loved ones off the hook.
As it turns out, when confronted with advanced care questions, people often choose less care than they would otherwise receive.
Palliative care, which focuses on relief for seriously ill patients, has been a part of this evolution. The medical community is accepting that it cannot save everyone and that heroic efforts can actually make lives more miserable. The growing hospice movement is also a critical component.
However, the government still has a role to play, not in deciding who lives and dies, but in making sure health care professionals are paid for their efforts.
Under the traditional fee-for-service regime, Medicare providers get paid for ordering tests, prescribing drugs, performing surgeries, etc., but not for important conversations that could shape the quality of life for seriously ill patients. “Hail Mary” surgeries are covered. Heading them off is not.
That’s not a healthy incentive. Medicare needs to be reformed so that advanced care conversations are encouraged and rewarded.
Paying for that is not the same as “denying grandma care,” as the demagogues are fond of saying. It is about educating people about the limits of medicine, ensuring they are in charge of their care and letting them live out life’s final chapter as they choose.
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