As was true of all topics medical, end-of-life decision making became a political battle in the middle of finalizing the Affordable Care Act [ACA] in 2009.
The ACA originally wanted to provide reimbursement to physicians (and other primary providers) if they spent time helping their patients decide what they wanted at the end of their lives, but this part of the law became the rumor about “Death Panels“, a term coined by Sarah Palin.
The uproar that followed that deception won “Death Panels” the 2009 “Lie of the Year” from the Pulitzer Award winning Politifact organization, but also resulted in the provision being stripped from the final version of the ACA.
Last July that decision was reversed, when Medicare rules were revised to provide funding for private conversations between patients and their doctors. Starting this past January, doctors can now bill Medicare $86 for a 30-minute conversation with their patient about what they would want in the future if they can’t speak for themselves at that time. It is an opportunity for patients to find out more about their alternatives, and physicians to come to know their patients that much better.
Isn’t the Government Just Saving Money Killing Off the Old?
There are still people who want you to think this is a government plan to force the elderly to die prematurely. But that ignores two things:
- all that is changing is providers can be paid for conversations most are already having. In the same way, they can bill Medicare for time spent conducting a physical exam, they can now be paid for however much time a person needs to make their end-of-life choices. The doctor can be paid for one conversation or a series- whatever the patient needs;
- the whole point of the conversation is for patients to make their own choices. It’s not a choice if the only option is to say “No” to life-extending treatment. People who want every possible life-prolonging treatment should say so- that is the point!
Cost and End-of-Life: The Connection
Maybe the reason the “Death Panel” rumor won’t die even 6 years later is because there is a connection between elderly medical care and cost, and you rarely hear straight talk about it.
A whopping 28% of Medicare expenditures are spent during the last 6 months of life. If this was because a person had asked for all care at all cost that would not bother me in the least. But really, how often is that true?
How many of those patients would rather have their pain controlled while dying at home or in a less invasive environment?
How often is the impetus to invest in surgeries, dialysis, intensive-unit care, and expensive medications being driven by the physicians, hospitals, or pharmaceutical and surgical supply companies that profit from all that spending?
More to the point- how much of that end-of-life intervention significantly prolongs life, or increases the quality of that time?
THAT is the true connection between cost and end-of-life care for the elderly.
But again- without any directive from the patient, those physicians (and their families) are making decisions in a vacuum. No one knows what the patient wants.
Spare Me Talk About Death Panels
The only way to stop the cycle of unwanted, invasive treatment of patients who can’t say “no” is for all of us to speak up while we can. That is why I am pleading with you to do so- whether you want palliative care only, or a double dose of all the interventions just listed. You need to let people know what you want- and you need to let them know now.
What we are protecting is the right we all hold most dear- our right to be able to control our own health care destiny. The reimbursement of physicians to provide more time to help us with these difficult decisions as we approach our final years is the right thing to do.
This is too important a conversation to politicize.
There is an easy 5 step process for how to do end-of-life planning that I borrowed from Speak Up that I recommend highly. They produced a 1.5-minute video outlining the steps that is a good place to start.
You also want to be sure that your documentation is in keeping with the requirements from your state. Fortunately, there are state specific suggestions for Living Wills freely available on the web, but your doctor, hospital, local library, and senior-citizen center are all good places to ask for the information/assistance you need.