If you think end-of-life care is a topic only for oncologists or gerontologists, think again.
Truth be told, we physicians traditionally and by design have avoided discussing end-of-life care with patients. For some of us, such discussions are too difficult or uncomfortable. For others, addressing the reality of death has wrongfully been considered a medical failure of sorts, despite a patient’s illness, age or condition.
If you think end-of-life care is a topic only for oncologists or gerontologists, think again. It’s for all of us who have patient contact, regardless of specialty. It is especially germane for primary care physicians who build trusting relationships with patients with a common understanding of patient prognosis and state of mind. A 2010 study from Johns Hopkins revealed that when people were given choices of where to get advance care planning advice, they overwhelmingly chose physicians. Despite that, we don’t initiate those conversations often enough, and patients are reluctant to do so when a standard primary care visit is only about 15 to 20 minutes.
Our culture values individual freedom and autonomy, yet we collectively abdicate those principles when it comes to advance care planning. It’s time to change that.
Following are five reasons why doing so is good for the patient, for the family, for the health care system and for the physician.
Completing an advance care plan (ACP) helps direct care according to one’s circumstances and values. It helps clinicians deliver personalized, humane service, respecting patients’ choices and values. What an unmarried 20-year-old desires will be different from what an 80-year-old wants. ACPs are living documents that should be updated as we age and as our relationships, values and health change.
People are living longer, more productive lives and increasingly want control of their end-of-life care. The best solution is for physicians to initiate the candid conversation and help patients complete advance directives (free documents, legal in every state, are available from multiple sources such as mydirectives.com), enlisting supportive services (hospice and palliative care) that are almost always covered by insurance. Only about 40% of Americans have done so. Now it’s time to make this a routine process and that includes a focus among minority populations where the rate of ACP completion is only about 20%. COVID-19 brought to light imbalances in our health care system, particularly among people of color. Let’s not continue to allow ACPs to be among those inequities.
Knowing what a patient wants or doesn’t want — and honoring these wishes — can reduce health care costs and waste. Thanks to increased health awareness, advances in diagnosis and treatment, and evolution of pharmaceuticals, the baby boomer generation is living longer. That’s a good thing. But caring for them is becoming more expensive. Approximately 10,000 baby boomers enter the ranks of Medicare daily, and annual Medicare expenditures are approaching $900 billion. Of that, it’s estimated about one-third is spent on the last months of life. Most boomers want the best of medical care when it’s appropriate and helpful, but not when they are long past any hope of recovery or meaningful life. More people are choosing to die at home or in hospice settings; these are choices that are less costly and more personal. Health care costs can be significantly reduced simply by respecting choices of individuals.
Physicians can now get paid for having this conversation. In the past, initiating discussions around dying and explaining the importance of having an ACP was not only difficult but time consuming — an exercise for which there was no reimbursement. Now, physicians with proper documentation can get paid for this using billing codes 99497 and 99498.
You can avoid lawsuits and litigation. If the quality, personalized care and financial arguments don’t move you, perhaps fear of litigation will. Typically, we know — and worry — about wrongful death suits. These happen when someone dies unexpectedly and negligence is alleged. Now there is a surge in “wrongful life” lawsuits that hold hospitals and health care workers accountable when they don’t obtain or ignore a patient’s legally documented wishes.
If these five reasons don’t make a strong enough case for physicians to engage with their patients in advance care planning, here’s one more: it is simply the right thing to do.
Dan Morhaim, M.D., is senior adviser at ADVault, Inc.. A career emergency room physician, he is the author of “Preparing for a Better End” (Johns Hopkins Press, www.thebetterend.com).