The Obama Administration has decided to pay doctors for discussing end of the life issues with their Medicare patients. You may recall that this would have been permitted by the 2010 health law, but the provision was dropped in the face of withering criticism by opponents of health reform, who dubbed these important conversations “death panels.”
The new rules are an important first step. Doctors absolutely should be paid for the time it takes to have these difficult conversations. But compensation alone is not nearly enough.
Here’s why: Early one morning in a hospital intensive care unit, I was shadowing a care team on their rounds. A patient in her 90s had been admitted from a nursing home with severe breathing problems.She had Stage IV lung cancer and congestive heart failure. A doctor, nurse, and social worker explained to her that she was very ill and gave her two options: They would stop aggressive treatment but make her comfortable. And she would likely die in a day or two. Or they could hook her up to a ventilator. They explained that the device would probably keep her alive for a few months, but also described how uncomfortable she would be.
The woman, who seemed surprised by her prognosis, chose the ventilator. And I could not help but wonder: Why did nobody talk to her about these choices long before this crisis? How could the system have failed her so badly?
If physicians are going to counsel patients on end-of-life choices, they first need to learn how to talk about these issues with their patients. They not only have to be trained in how to use the right words and body language, many need to fundamentally rethink their own attitudes about treatment and death. Today, too many physicians equate the death of a patient as failure. As a result, they and their patients suffer.
Dr. Dan Sulmasy, who is both a physician and a Franciscan friar, has written powerfully about the intersection of medicine, faith, and death. In one article, he says that doctors “have three great attachments: The need to be in control. The need to be effective. And the need to be right.”
Death confounds all three.
But giving patients the information they need to confront the end of life will take more than just retraining doctors. It will also require hospitals, nursing homes, and other health facilities to change they way they approach the dying. For instance, once a patient is admitted to a hospital, it is too easy to become sucked into the powerful and seemingly inexorable cycle of treatment and diagnostic tests. The pressure is always to “do more” and it is reinforced by both a perverse payment system and, often, the demands of family members.
We know how to break that cycle. For example, well-designed palliative care programs can increase the comfort of chronically-ill patients. And while terminally-ill palliative care patients often request less treatment, they also live longer.
But palliative or hospice care remain an after-thought in too many hospitals. These programs are not given the resources they need. They are not well-integrated into the hospital’s practice of care. And attending physicians often wait too long before requesting palliative care consults and then ignore their advice.
Conservative critics are still opposed to these end-of-life dicussions. Robert Pear’s New York Times piece that first reported the new rules quoted Elizabeth D. Wickham of a group called LifeTree as saying that end-of-life counseling would encourage patients to forgo or curtail care, thus hastening death. “Patients will lose the ability to control treatments at the end of life,” she told The Times.
Of course, Wickham has it exactly backwards. Good physician-patient discussions will give patients more control over their treatment at the end of the life, not less. But only if health providers are fully prepared to have these conversations.
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