Though I hesitate to wax political, I feel compelled to talk about the hue and cry about the supposed “death panels” piece of the Democratic healthcare reform bill that is working its way through Congress. The area in question, Section 1233 of the House bill, proposes, among other things, that physicians who hold advance-care planning consultations with Medicare beneficiaries be reimbursed for their time. Whatever else you may think about the bill as a whole, this section does not, as critics suggest, mandate government-sponsored euthanasia. Yet as I write this, it looks to be so controversial that it likely will be dropped from the bill altogether.
Which is a crying shame. It took a healthcare crisis in my own life to spur my husband and me to have those difficult discussions between us, to sign health proxies and living wills that specify our wishes for care if we are unable to communicate them. My doctor at the time was inordinately good at spending time counseling me on different healthcare issues, but this never came up. Which is fine with Sen. Chuck Grassley (R-Iowa), the top Republican on the Finance Committee, who famously said at an Iowa town hall meeting in August: “I don't have any problem with things like living wills. But they ought to be done within the family. We should not have a government program that determines if you're going to pull the plug on grandma.”
But the family, unless it is made up of healthcare professionals, likely doesn't have all the information it needs to make intelligent end-of-life decisions about respirators and feeding tubes, hospice and palliative care. Doctors do. Why shouldn't they be paid for their time in informing us about end-of-life care, just as they get paid to discuss smoking cessation or obesity or any other healthcare-related subject? In this case, it literally is about life and death.
It also makes fiscal sense. According to a Harvard study released earlier this year, end-of-life counseling resulted in not just a better quality of life for patients with advanced cancer, but also in lower healthcare costs: Those who had the end-of-life discussions with their doctors spent an estimated average of $1,876 on healthcare expenses during their last week of life, compared with $2,917 for those who didn't. This and other studies also have found that intensive care, which costs more than hospice, led to a worse quality of death. This, of course, is where the fear comes in — that to save money, the government will insist on pulling poor grandma's plug instead of following her wishes. But all the bill's provisions ask is that docs be paid to explain her options so she can make an informed decision on her own.
Of course, it follows that if doctors get paid to do it, they more likely will. (Let's save the discussion over whether or not it's a good idea to make these discussions mandatory for another time.) This could be a good opportunity for continuing medical education providers, who are positioned to provide just the kind of education physicians would need. It also would make the position of CME as a champion of better, more effective healthcare even stronger if providers can develop and disseminate information not just on all the options docs should cover, but also on how to discuss end-of-life care with the sensitivity and understanding needed to allow patients to really hear what is being said.
On a personal note, I would like to thank the veterinary schools and associations that do provide end-of-life education to their practitioners, especially to the vet who helped us through the passing of my best friend and constant companion of 14 years, my dog Augie, in August. My wish is that all humans, and those who care for them when they are unable to care for themselves, get the same level of compassionate counseling in their time of need.