The public overwhelmingly thinks doctors should have end-of-life conversations with older patients. It even thinks Medicare ought to pay for those talks. It just doesn’t want to have them, at least not yet.
Those are results of a new Kaiser Family Foundation poll, which found that 89 percent of respondents felt physicians should discuss end-of-life choices with them. But only 17 percent of all those surveyed, and about one-in-four older adults, said they have talked about death and dying with their doctors. The better news: About one-in-three people who have a debilitating disease have had “the conversation” (to borrow the title of Angelo Volandes book).
Medicare is currently finalizing the rules that will allow the program to pay physicians to talk about end of life.
And separately, senators Mark Warner (D-VA) and Johnny Isakson (R-GA) have re-introduced the Care Planning Act, a measure that would go one more step and have Medicare pay for the development of formal care plans for patients with terminal diseases.
Eventually, I suspect that end-of-life discussions will become a routine part of many physicals, but it won’t happen overnight.
That’s because these conversations are not just about money. Many docs don’t want to have them because they are uncomfortable with them. They have not been trained in end-of-life conversations (even when they are not about imminent death) and many are just not very good at it. And, as in most things, bad conversations can be worse than no conversations at all.
My guess is this transformation will happen in a couple for stages. First, Medicare will create a payment code and (of course) a set of rules about what is, and what is not, a reimbursable conversation. Then, increasing numbers of physicians will get trained in how to have these talks, and most important, how to encourage patients to engage with them on this important issue. Because, really, the physician’s job here is to listen, not to talk.
It will be interesting to see where this idea starts to catch on. Will it begin with big multi-specialty medical practices, with docs affiliated with teaching hospitals, in urban practices with highly-educated patients, or in small rural practices?
Then, there is the fascinating—and fast-evolving–politics of this issue. During the debate over the Affordable Care Act in 2010, congressional Republicans seized on a similar provision of the bill to accuse the Obama Administration of encouraging doctors to stop treating older patients. They railed about death panels (they actually did this about two separate provisions of the ACA). The issue become one of those mini-controversies that so often afflict Washington, and the White House retreated.
Later in 2010, Medicare quietly tried to do the same thing administratively. Conservatives howled. And to its shame, the Administration backed off again.
But now, the issue seems to have just…faded away.
Medicare’s proposed rules have generated some conservative push-back, but congressional Republicans seem far more focused on Planned Parenthood than on end-of-life discussions. And, of course, there has been a growing movement in the states that would allow patients with terminal illnesses to take active steps to end their lives.
In the wake of that movement, paying for end-of-life conversations between docs and patients just doesn’t have the political resonance it did just a few years ago.
The tide is turning. Slowly, the public, doctors, the government payment system, and even the politicians are coming to realize that A) we are not immortal and B) It is a good idea to plan—as best we can—for how we want to die.
This is not necessarily about physician-assisted suicide. It is about whether we want to be hospitalized in our last days, whether we want aggressive measures to keep us alive, or whether we want to die quietly at home.
In many cases we can choose. But first, we have to talk about it—with our families, our spiritual advisers and our doctors.