Well, not death panels per se, but a shift from our insistence that death is something we can defeat with technology to an understanding that, despite our best efforts, the death rate in this country is still 100 percent. The only question about our death is whether we are in charge, or whether we want to cede that power to our families and doctors who, evidence shows, are often reluctant to give up, particularly when there are more tests, treatments, and expensive technology to throw at patients.
Two personal stories vividly illustrated this disconnect. Last year, doctors removed the breast of my husband’s 80-year-old aunt and started her on chemo when she was diagnosed with cancer, despite the fact that she has late-stage dementia.
And doctors are treating–albeit not aggressively–the early-stage vulval cancer my friend’s 90-year-old mother-in-law was recently diagnosed with.
And yet, a survey of nearly 1,700 California adults found that while more than 80% of patients think it’s important to have their end-of-life wishes in writing, less than a quarter did. Only 8% said a doctor had ever talked to them end-of-life issues.
Talking to patients about end-of-life issues could improve the way they die. So why doesn’t Medicare, which covers nearly every American 65 and older and spends about a third of its annual budget on care provided in the last year of life, pay doctors for counseling patients about end-of-life issues?
Oh yeah, because that would mean “death panels” deciding who lives and dies.
Give me a break.
We shouldn’t change how we die because it will save money. It will, but it will be a one-time savings and won’t substantially affect growth in health care costs. We should change how we die because it could mean a more dignified, less painful death for millions of Americans.
How you die depends, in part, on where you life. A seminal study by the people who bring you the Dartmouth Atlas of Health Care, which studies regional differences in medical services, found huge variations in how people die across the country. For instance, if you live in Grand Rapids, Colorado, you’ll spend about a day in the intensive care unit (ICU) before dying; but if you live in McAllen, Texas you’ll spend an average of 6.5 days–despite having similar health issues to the person in Grand Rapids. You’re also far more likely to die in the hospital in McAllen–about 45% of patients do, versus 16.7% of Grand Junction patients. And, oh yeah, the fact that Medicare spends nearly three times as much on end-of-life care for McAllen beneficiaries as Grand Junction beneficiaries doesn’t mean those in Texas are getting better care; in fact, studies find that death rates, quality of care, and patient satisfaction are often worse in areas with higher spending.
For just one week in 2011, Medicare covered end-of-life counseling. That’s not counseling patients to commit suicide when they become terminally ill or their organ systems begin failing. It’s not telling them that their care will be discontinued when their condition becomes hopeless.
Instead, it’s counseling to encourage them to think about how they want to die. Hooked up to tubes and machines in a sterile hospital? At home with their pain and respiratory distress controlled but no “heroic” interventions? In a hospice receiving palliative care and emotional support? Any is fine. As long as it is the patient’s choice.
And guess what? Most Medicare patients say they don‘t want heroic measures at the end of life. They want to die at home, not in a hospital. End-of-life counseling, evidence shows, results in just that.
Sadly, Medicare reimbursement for such counseling lasted just a week before the rhetoric about “death panels” and rationing overcame common sense.
I’m sure many physicians still provide such counseling on their own time, reimbursement be damned. They shouldn’t have to. This is one of the most important conversations doctors can have with patients. It takes a great deal of time and, yes, courage to broach this topic with a patient. Doctors need training in how to have these conversations and they deserve to be compensated for their time.
As an article from the American Enterprise Institute noted: end-of-life care is “one of the most significant problems in US healthcare.”
So why won’t we address it?