Advancements in medicine have dramatically expanded life expectancy in the United States. An average American born in 1900 had a life expectancy of 47 years; the same American born in 2013 can expect to live to age 78.

It is not just that we are living longer; we are dying differently. We are less likely to die suddenly or from a short illness. We are more likely to have a long period of slow decline during which time a medical system may offer interventions that extend life, but without improving its quality. Most people say they wish to die at home, but most of us will die in an institutional setting.

There is an increasing awareness of the need to start talking more about end of life treatment options for those with life limiting illnesses in the context of what we want for ourselves, and not based solely on what medical treatments are available.  Thought leaders from the Institute of Medicine to Dr. Atul Gawande have spoken out about the need for physicians and patients to actively work together to create a plan of treatment that meets the informed preferences of patients.

 

The New Medicare Coverage for End of Life Discussions

Medicare agrees that there is an unmet need for more discussion and education about end of life care. Starting this January, Medicare will pay physicians for holding advanced planning discussions with their patients. The physicians will receive $86 for the first half-hour discussion and another $75 for an additional half hour.

Among the common sense features of this new coverage are

• A reimbursement structure that acknowledges that these discussions take time and cannot be squeezed into a 15-minute appointment.

• No limits on the number of times that a patient and physician can have these end of life treatment discussions, reflecting an awareness that the decisions arising from these conversations may need to be re-evaluated as patients’ conditions change.

• A modest payment structure that will prevent physicians or critics from alleging that a physician is having end of life discussions to increase income.

 

Untested Waters

Having a framework in place that allows for these discussions is only a beginning. Both patients and physicians will need to learn how to make these discussions meaningful and effective. Medical schools and continuing medical education will need to train physicians to talk about subjects that make people uncomfortable. The attitude that death is a defeat needs to be modified to see it as a part of life,  a part that patients need guidance to navigate.

Patients will need to learn how to ask the right questions so that the physician can plan a treatment program that is consistent with their values and priorities. At the end of a discussion, patients and physicians alike should know the answers to these questions:

• What might happen to me as my disease progresses?

• What are the treatment options that you are likely to recommend?

• What are the side effects of these treatments? What are their success rates? Will the treatment either improve the quality of my daily life or allow me to do something that is important to me?

• How likely is it that the treatments will make me feel worse or result in my permanent placement in an institution?

• Can I receive treatment and remain at home?

• What is the best way for me to document my decisions and preferences so that the medical institution treating me to will know and follow my wishes?

• If I change my mind about the treatment that I want, how should I communicate that to you?

• What are my priorities in managing my illness: extending my life, maintaining my independence, being pain free?

• Are there any milestones that I want to live for?

• What are the things that make my life worthwhile?  Would I want to stop treatment if I was no longer able to do those things?

It will take time to become good at these conversations, but the fact that Medicare now acknowledges the need for them as an on-going part of treatment gives everyone a framework to work from.