What would Dad want? Doctors now can get reimbursed for advance-care planning
This month The Centers for Medicare and Medicaid Services released a proposed Medicare Physician Fee Schedule that would allow physicians to be paid for advance-care planning discussions with their patients. Reimbursement for these important and complex discussions supports their value to patients and families. A lack of reimbursement discourages them.
Advance-care planning is the process of discussing and recording preferences of patients who may lose the ability to communicate in the future. Many chronically ill people face a period of impaired cognitive functioning at the end of life. Despite this, even cancer patients report that they have not discussed end-of-lifecare preferences with their physicians.
Only one third to one half of Americans have completed advance-directives such as a living will or assigned a healthcare surrogate or durable power of attorney for healthcare. This leaves decision-making during a time of medical crisis to the nearest relative. In the absence of prior discussion, that person, often a spouse or child, may lack the confidence and clarity to choose as his or her loved one might want. The patient may receive unwanted, ineffective, costly and invasive medical interventions that may not extend life or may diminish quality of life.
Recent studies show that people who participate in end-of-life planning are more likely to have their wishes followed, have family members who suffer less stress, have fewer hospitalizations and incur lower costs in the last six months of life than people who have not planned. Honoring patients’ treatment choices is a key predictor of high-quality end-of-life care. It spares the family the emotional burden of making decisions for which they are unprepared, the moral distress of not knowing whether they decided well and the divisiveness of arguing over who knows best what “Dad would have wanted.”
Some argue that these discussions amount to rationing care and an attempt to deny elderly people access to treatment that will benefit them, akin to counseling them on how to die sooner.
This is a deeply flawed mischaracterization. In fact, if an individual’s wishes are for extensive testing, ventilators, feeding tubes and surgeries regardless of prognosis or the absence of benefit, advancecare planning is the opportunity to make that known. These preferences can be documented, and a trusted person can be appointed to ensure those wishes are communicated.
Regardless, most people want the ability to say “No” to treatments under conditions where the intervention might extend life but leave them with severe side effects, on permanent life support, unable to walk or talk or in a persistent unresponsive state.
Each one of us, in turn, will come to the end of our lives. The CMS proposal promotes self-determination, human dignity and informed decision-making so that families can experience this sacred time with more control and less uncertainty. The answer to the question “What would Dad want?” can be answered by Dad himself.