Are Doctors Ready to Talk About End-of-Life Care?
New Medicare provisions reimburse for it, but training is a separate issue
About to board a flight back to his district, Rep. Earl Blumenauer, D-Ore., is downright effusive, calling a health care policy that takes effect Jan. 1 "profound" and nothing short of "revolutionary." On that date, Medicare will greatly expand its reimbursement to health care providers who talk with their patients about end-of-life choices, also called “advance care planning.”
It was Blumenauer who six years ago touched off the frenzy about health care rationing and so-called death panels when he introduced a provision to what would become the Affordable Care Act (Obamacare). A leading advocate of personalized medicine, Blumenauer and a coalition of health care groups lobbied the federal government to widely reimburse providers for voluntary end-of-life discussions with patients. His provision was stripped from the ACA, and only this year did Medicare change its policy to increase coverage of advance care planning.
Medicare already pays for these conversations when they’re part of a new enrollee’s “Welcome to Medicare” consult with a physician. But starting next month, under new reimbursement codes proposed by the American Medical Association, the planning sessions will be covered by Medicare no matter when patients want to have them. Health care professionals will be able to bill Medicare $86 for the first half hour of an advance planning conversation ($80 in a hospital) and $75 for an additional 30 minutes.
A Shift in Mindset for Doctors?
But how prepared are frenetic doctors to slow down and help patients make end-of-life decisions? As Dr. Atul Gawande, Next Avenue’s Influencer of the Year, noted in his best-selling book and PBS Frontline documentary Being Mortal, few doctors have the specialized skills that geriatricians and palliative care doctors have developed to effectively talk with their patients about end-of-life wishes.
"It's a huge problem," says Dr. Susan Block, director of the Serious Illness Care Program at Ariadne Labs, a collaboration of Brigham and Women's Hospital and the Harvard School of Public Health. "This particular kind of conversation is at the intersection of two topics that medical schools have by and large avoided — end-of-life care and communication."
By contrast, Dr. John Prescott, chief academic officer at the Association of American Medical Colleges, says the country's 145 medical schools have made "significant changes to their curriculum in both-end-of life care and communication. One hundred percent of medical schools have required courses on palliative care. There are few conversations between doctors and patients that are more important.” Still, "Do I think the American medical profession is totally up to speed and ready to have these discussions? The answer is no,” Prescott adds. “I still think we could improve medical education in this area. There’s no doubt."
“Medical schools are improving in this area,” Block concedes. “But it’s still woefully inadequate. Doctors who conduct the wrong kind of conversation with their patients don’t get the key information about what’s important to the patient.”
“Here’s an example of something that happens all the time,” she continues. “The patient with a terminal illness is asked, ‘Do you want us to do everything to help you?’ What that means to the doctor is ‘Do you want resuscitation? Do you want to go to the ICU? Do you want to go through many intensive procedures that bring with them a certain amount of suffering?’ But from the patient’s point of view, who wouldn’t want us to do everything? You need to explain the trade-offs, that extending life may mean less quality of life, sending you to a nursing home, shuttling back and forth for hospital visits.”
When families are not included in the conversation, she adds, “they’re not prepared to act as a surrogate decision-maker for their loved one.”
Teaching the Art of Difficult Conversations
Ariadne Labs is working with large health groups to develop training programs for doctors, says Block, who is also a founding chair of the psychosocial oncology and palliative care department at Dana-Farber Cancer Institute and an advisor to the nonprofit The Conversation Project, which urges people to express their end-of-life wishes. But “we need a national effort to integrate this kind of approach."
For now, health professionals can access Ariadne Labs’ Serious Illness Conversation Guide, which gives them seven key questions to ask during an end-of life conversation with a patient. Among them: “If your health situation worsens, what are your most important goals?” and “If you become sicker, how much are you willing to go through for the possibility of gaining more time?”
Centers for Medicare & Medicaid Services (CMS) does not distribute information to providers on how best to conduct end-of-life conversations with their patients. While the agency declined to be interviewed on the subject of physician training, spokesman Aaron Albright said, “The stakeholders who recommended this policy are now working to help providers learn best practices for providing advance care planning. We applaud these efforts and encourage the professionals who care for Medicare beneficiaries to take advantage of this education.”
‘Doctors Die Differently’
Blumenauer says there’s too much work left to take a victory lap. He'll introduce legislation in the next Congress to not only better train health care providers, but also make sure that when they have end-of-life conversations, the information is captured and follows patients across state lines in electronic medical records. “We’ve now got to make sure that the patient’s wishes are actually observed.”
The goal of an end-of-life conversation — ideally, multiple conversations as circumstances change — is for people to clearly state their choices, he says. “For me and members of my family, we want to know what we’re getting into and don’t want unnecessary pain and suffering.”
As these conversations between doctors and patients become routine, it will reduce the percentage of Medicare dollars that flow into the last year of life, Blumenauer believes. That’s because more people will make the kinds of informed choices that doctors make for themselves today.
“Doctors die differently than the rest of us. As a class, doctors have less overall health care in the last year of their life than the typical American,” he says. “It’s not that they can’t afford aggressive treatment, it’s that they know what works. I’m hopeful we’ll have the same choices as doctors and will know what works, leading to less unnecessary care, unnecessary suffering and higher quality of life in our final years of life.”