By Mark Miller
CHICAGO, April 21 (Reuters) - Older patients want to talk with their doctors about how they will die, but are doctors ready to have the conversation?
Medicare began reimbursing physicians in January for time spent discussing their patients’ end-of-life wishes. While 95 percent of U.S. physicians support the new benefit, only 14 percent say they have yet billed Medicare for advance planning patient visits, according to a survey of more than 700 U.S. doctors by three healthcare foundations.
The new Medicare policy aims to help people learn about their healthcare treatment options, determine the kind of care they want and share their wishes with family, friends and healthcare providers.
An advance directive should be captured in writing, and entered into the patient’s electronic health record. The conversations can take place during a senior’s annual wellness checkup, or during counseling sessions in hospitals. Nurse practitioners and physician assistants also can be reimbursed for planning sessions. The Medicare benefit is not limited to a single conversation, or to patients close to death.
Older patients want to have these conversations - a poll last year by the Kaiser Family Foundation found that 80 percent like the idea. It is a sensible reform that can save Medicare money over time, because end-of-life discussions very likely will reduce healthcare costs. Roughly one-fourth of Medicare payments cover patients in their last year of life.
But the healthcare system is not ready to get this done on a large scale. Only 29 percent of doctors surveyed say their practices have formal systems in place for assessing end-of-life wishes. Forty percent say their electronic record systems do not include information on advance directives. Just 29 percent say they have had any formal training on end-of-life care, and 46 percent say they are not sure what to tell patients while having these conversations. (The research was commissioned by the John A. Hartford Foundation, the California Health Care Foundation, and Cambia Health Foundation).
Kaiser’s survey of patients reflects similar findings. Just 17 percent say they have had an advance planning conversation with a doctor or other healthcare provider - including 34 percent of people age 75 or more, 23 percent of people age 65-74, and 19 percent of those age 50-64.
“It worries me that we have this big disconnect,” said Dr. Tony Back, co-director of the Cambia Palliative Care Center of Excellence and professor of medicine at the University of Washington in Seattle, referring to the healthcare system's poor job of engaging with patients on end-of-life conversations. “If you are a patient with a serious illness, you cannot count on running into a doctor or nurse who can guide you through a conversation about what you want at the end of life.”
Patients should not be shy about asking healthcare providers to hold these conversations. Family members should consider being proactive as well, making sure to have the talk with loved ones.
One excellent resource that can help with these difficult conversations is the Conversation Project which was founded by Pulitzer Prize-winning columnist Ellen Goodman after she was forced to make decisions for her own mother for which she was unprepared. The project’s website includes a starter kit with free resource guides that can be downloaded.
Another go-to source is "Knocking on Heaven’s Door: The Path to a Better Way of Death” by Katy Butler, the story of the “good” and “bad” deaths experienced by her own parents, along with thoughts on how to navigate the healthcare system (http://reut.rs/1SqPi0u).
The physician survey did contain some good news: 75 percent of doctors predict the new Medicare reimbursement will make it more likely that they will have advance-planning talks with patients. Let’s hope that happens. These conversations can make a big difference in the quality of patient lives.
“You may want to do all the medical care that is reasonable and when it’s your time pass away quietly in your own bed,” said Back. “But if you don’t have this conversation and your doctor doesn’t know what you want and your family doesn’t know what to do, you can easily wind up in intensive care with a catheter in your bladder, intravenous lines in your arm, in a bright noisy place that will be the last moments you have on this earth.”
(The opinions expressed here are those of the author, a columnist for Reuters.)