The news earlier this month that Medicare plans to reimburse doctors for conversations with patients about medical treatment at the end of life represents an important step forward for public policy in health care. It also signals a welcome shift to a more open attitude toward a subject most people would rather avoid. In short, the agency is proposing to support open discussions with medical professionals about the way we want to die. Decisions by Medicare, which insures 55 million older Americans, often set the standard followed by private insurers as well.
In recent years, more attention has been drawn to end-of-life issues — specifically, what kind of treatment do we want, or not want, in life’s final stages. What’s more, how do we make our wishes known, how do we guide our caregivers so that they’ll know what we want when we can no longer speak for ourselves? It’s a topic that’s been uncomfortable for physicians as well as patients and their families. As the surgeon and author Atul Gawande pointed out in his best-selling “Being Mortal,” it’s a subject he himself avoided as a physician until he was faced with the terminal illness of his own father.
Perhaps the low point in the discussion about public health policy regarding end-of-life issues came in 2009, when Sarah Palin coined the term “death panels” to describe provisions in the proposed Affordable Care Act. But last year, a nonpartisan committee reported that major changes were needed to confront the issue. “The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and former United States comptroller general, the committee’s chairman. “The current system is geared toward doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly,” Walker told The New York Times.
There are, of course, still objections to sponsored end-of-life discussions by those, such as the National Right to Life Committee, who feel that health care providers will pressure patients into forgoing treatment. But that point of view has become an outlier. For the most part, avoidance of these conversations is based more on emotion than principle. A national survey commissioned by the nonprofit group The Conversation Project reported that 90 percent of those polled thought it was important to have family end-of-life discussions, but only 30 percent have them.
Medicare hopes to file its proposal by Nov. 1, following the current 60-day comment period, with the idea of activating the new regulation by Jan. 1. At this point, the proposal would allow nurse practitioners and physician assistants as well as doctors to be reimbursed for face-to-face meetings with patients, relatives, and other caregivers. Medicare should also seriously consider including social workers and other psychiatric caregivers in the group of those covered. As has been pointed out, these discussions cannot be covered in a simple checklist — they must be real conversations, and can entail several meetings. Training is required to conduct these meetings effectively — training more common to social workers and mental health professionals than doctors and nurses.
Still, the Medicare proposal deserves support. These conversations can be hard but, as with a lot of medical treatment, can prevent further suffering down the line. Reimbursing health care professionals will help encourage such conversations. Even families who at least notionally agree with the concept of end-of-life discussions would probably rather put them off, indefinitely. But as Dr. Lachlan Forrow of Beth Israel Deaconess Medical Center has said, “It’s always too soon, until it’s too late.”