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Sunday, January 2, 2011

Obamacare's end-of-life mistake

Last week I saw my patient Sandy for a routine physical. He is in his early 80s, has high blood pressure, back and leg pain and high cholesterol, but is otherwise built like a truck. Beginning this year, Medicare will begin to reimburse me for a yearly preventive physical, including a discussion of end-of-life options. But since Sandy was already in the office, I decided not to wait.

We decided together that he would want "everything done" unless he were brain damaged, in a coma with little hope of waking up or had metastatic cancer that was resistant to all treatment.

Afterward I asked him how often he would like to have this discussion. "Once in a lifetime is enough," he said. "What would you think if I tried to bring it up every year?" I asked. "I'd think I was about to die," he replied.

Like many physicians, I talk to my patients about how aggressive they want me to be if and when they are dying. But I don't see a role for the government incentivizing this kind of planning session on a regular basis except as a way of advancing their own agenda, which clearly is decreasing end-of-life care.

Financially, one can understand why the government wants to attack this area of care. Last year alone, Medicare paid $55 billion just for doctors' and hospital bills connected to the last two months of patients' lives. If you want to "bend the cost curve," you can't ignore this spending, particularly with the baby boomers aging.

But the practice of medicine is about saving people, not pinching pennies. And in the real world of medical care, "advanced directives" have a limited value when a life-threatening illness actually comes. Dying is almost never as envisioned; people who are sure they would want to give up often wind up being the biggest fighters against death. In the fight against disease, it is morally difficult for both doctors and patients to shut down the machines when there is still hope left.

My job as a doctor is much more about conducting a war against disease than it is about planning for withdrawing care. Dr. Donald Berwick, the new administrative head of Medicare and Medicaid services, sees things far differently than I do. He has said that "using unwanted procedures in terminal illness is a form of assault." But for practicing doctors like me, "terminal" is rarely an accurate term. With the latest techniques of medical care - which are advancing by the year - most illnesses are not terminal, but treatable until very late in the game.
This is why I and other doctors protested against the proposed provision in the health care law that sought to establish end-of-life advisory panels in the first place. It is mindboggling that Berwick ignored this wildly unpopular provision, which was deleted from the final bill, and is now instituting a regulation that will pay for voluntary end-of-life planning discussions yearly.

I have no problem with Medicare providing an incentive for end-of-life discussions, but offering this incentive yearly will lead to excessive use. Having too frequent end-of-life discussions sends an unfortunate message to the patient that death could be imminent. How much angst and excess worry will result from death planning sessions?  (continues here)

1 comment:

Anonymous said...

I totally agree with the author of this article. It's definitely inappropriate for a doctor to bring up the subject of death every year with any patient. It's unnecessarily intrusive and indicative of age discrimination.