The recent elimination of reimbursement for advance care planning from the Medicare regulations is disappointing. Physician blogger Ed Volpintesta observed that since the issue of advance care planning has become politicized, we are losing track of why these conversations must take place. Dr. Volpintesta astutely wrote, "Doctors have these discussions to make sure that patients get the care they want."
This was precisely the intent of the Medicare provision--to encourage doctors and patients to start the conversation during the annual wellness visit, not at the patient's deathbed. Introducing the subject of advance care planning during a routine office visit, long before a patient becomes seriously ill, makes it easier for patients and their families to think through end of life issues more rationally and carefully. Advance care planning can also minimize the emotional and physical stress of serious illness when the time comes.
Dr. Alexi Wright, an oncologist at Boston's Dana-Farber Cancer Institute, has found that such conversations can help patients preserve quality of life, minimize suffering and help families cope. Indeed, NY Times columnist Jane Brody recently related how her husband's advance directive allowed her to "say meaningful goodbyes and spare him unnecessary physical and emotional distress in his final weeks of life."
So where does this leave us? The critics and supporters are both right--the primary focus on advance care planning should never be about the money, though the associated savings can be significant. Helping patients plan the end of their lives is an important part of the patient-provider relationship. Clinicians, however, may need to initiate the conversation since research has shown many patients believe it's the physician's responsibility to raise the issue. The Agency for Healthcare Research and Quality (AHRQ) has some suggestions on how clinicians can begin this discussion.
How do you start the conversation with your patients?