She didn’t want to spend the rest of her days seeing doctors, the 91-year-old woman confessed to Dr. Kevin Newfield as he treated a deep wound on her arm.
“You don’t have to, but you have to tell me what you do want,” Newfield replied.
“I’m not afraid of dying. I’m afraid of being 106,” she told the surgeon and her daughter, who was in the room with them.
The woman’s spontaneous admission in Newfield’s south Florida office that January day triggered a 20-minute discussion about living wills, hospice and other end-of-life issues, Newfield said.
An orthopedic surgeon who sometimes performs amputations, Newfield is comfortable having those conversations.
Many doctors are not, but a Medicare policy, known as advance care planning, that took effect in January could help change that.
Physicians can now bill Medicare $86 for an office-based, end-of-life counseling session with a patient for as long as 30 minutes. Medicare has set no rules on what doctors must discuss during those sessions. Patients can seek guidance on completing advance directives stating if or when they want life support measures such as ventilators and feeding tubes, and how to appoint a family member or friend to make medical decisions on their behalf if they cannot, for instance.
The new policy reflects Americans’ growing interest in planning the last stage of their lives when they may be unable to make their wishes known.
In 2014, the Institute of Medicine, an influential panel of experts, found that the nation’s health system was not adequately dealing with end-of-life care, and among its recommendations was that insurers pay providers for advance care planning discussions.
Last September, a Kaiser Family Foundation poll found 89 percent of the public said that doctors should discuss end-of-life care issues with their patients, though just 17 percent of Americans — and 34 percent of people 75 and older — said that they have had such conversations. (KHN is an editorially independent program of the foundation.)
Under the new Medicare policy, doctors can give end-of-life advice during a senior’s annual wellness visit or in a routine office visit. Nurse practitioners and physician assistants can also get paid for having the talks.
“For doctors already providing this counseling the payment is an added benefit and for doctors on the fence about talking about the issue with patients, this may be enough to inspire them to try it,” said Paul Malley, president of Aging with Dignity, a national advocacy group based in Tallahassee, Florida.
Newfield, the Florida surgeon, is less optimistic. He said he doesn’t think the money will cause him to initiate more end-of-life discussions — and that doctors who weren’t doing them before now are unlikely to start. After all, said Newfield, doctors make money by keeping people alive.
The payment idea was first floated in 2009, as part of the congressional debate over the Affordable Care Act. Back then, a proposal to have Medicare pay for such discussions sparked political controversy and fueled concern that they would lead to so-called death panels that could influence decisions to avoid medical care. The proposal was quickly dropped.
Medicare’s policy now has broad support from health providers and patient groups, but neither physicians nor the American Medical Association foresee a surge in end-of-life planning among Medicare’s more than 50 million enrollees. The AMA, which supports the reimbursement, estimates Medicare will pay for fewer than 50,000 counseling sessions in 2016.
The numbers may well be held back by the small reimbursement rate for half an hour of counseling, but another obstacle rests with doctors themselves. Many are not trained to offer such advice or they are uncomfortable talking about it with patients.
“Just The First Step,” the journal Health Affairs headlined an article about Medicare’s new policy in its March issue.
“The perception that lack of training could be a major stumbling block to the greater implementation of advance care planning is widely shared,” wrote David Tuller, a lecturer at the University of California, Berkeley, School of Public Health.
“A lot depends on how you deliver the message and how you go about it,” said Dr. Jay Poonkasem, who specializes in palliative care in Clearwater, Florida.
“We will see more of this counseling, but only if doctors feel more comfortable and are trained in the right way to handle talks about end-of-life and advance care planning.”
Medical schools such as the Cleveland Clinic Lerner College of Medicine and the University of California, San Francisco, have recently begun expanding training on the subject.
At UCSF, all medical students are taught how to conduct advance care planning discussions and educational programs also exist for residents, nurses and other physicians at the hospital.
“This kind of training is crucial — one of the things that gets in the way of understanding and using patient preferences is that clinicians are often uncomfortable having these challenging conversations,” said Dr. Robert Wachter, professor and interim chair of UCSF’s Department of Medicine. “The issue of end-of-life conversations is so compelling and fraught — teaching it also allows us to teach about more general communication skills.”
Some doctors admit they could do better.
Dr. Scott Dunn, a family physician in Sandpoint, Idaho, said he regrets not having done more recently to help a 76-year-old patient avoid spending his final weeks in intensive care, connected to machines breathing for him and feeding him. That meant the patient may have needlessly suffered and cost the health system tens of thousands of extra dollars, he said.
“I wish I had taken the time months earlier to have that end-of-life discussion, but I did not,” he said.
Dunn said the incentive payment will entice him to have more such discussions with patients, but they won’t become routine in his practice. “Medicare pays us more to do other stuff.”
Michael Guarino came to a different view after watching his elderly father die last year, weeks after he became unable to move or talk. Guarino decided then that the 800-physician organization of which he is executive director — the Independent Physician Association of Nassau/Suffolk Counties in New York — would include end-of-life discussions for all adult patients.
To guide those discussions, the association’s physicians and nurses use a 12-page booklet called Five Wishes, which outlines how patients can designate someone to make decisions on their behalf if they become unable, as well as choose what treatment they want, if any, at the end of their life.
Dr. John Meigs, Jr., a family doctor in Centreville, Alabama, and president-elect of the American Academy of Family Physicians, said he sees value in doctors helping patients prepare for death.
Last July, a stroke left a 95-year-old nursing home patient of his with difficulty speaking and swallowing. The woman’s daughter questioned Meigs’ decision not to give the patient a feeding tube. Meigs reassured the daughter that her mother had made clear she didn’t want that in many talks with him and in her advance directives.
No heroic measures were made and the woman died a few days later.
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