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?
Posts
.png)
4 comments:
Advance care planning and conversation provided a much needed and conscious decision in the way we faced what life was left. Instituting a DNI and DNR directive was not easy and took a very unsettling conversation between two people who had spent 40 years together, yet were still very young (55). It did not help however, as the day of death occurred in an emergency room where instead of having those that knew the patient and his family's decisions and wished, there was chaos and surprise. Record sharing and knowledge of prescribed medications are not always readily available yet in this city, it should be easily attained through the system of "partners". My hope is that the future care of patients facing difficult decisions will be met, whether in the emergency room or in their own homes, with understanding and compassion from all those who direct the traffic in the face of grave illness.
Hi Nancy,
Its personal stories like yours that are the best argument for the advance care planning. As you point out, the need for an advance directive may arise suddenly, well before you or your loved ones expect it. You also raise an excellent point about the need to make these directives accessible anywhere, at any time, and in any place.
Thank you for sharing your story and contributing to the dialog on this important topic. Julie Rosen
Julie,
When my children were six and three years old, I became legally responsible for both parents who were dying simultaneously, a seven year commitment. I was their health care proxy and, unfortunately, was responsible for terminating life support for each when they passed. So this issue resonates with me.
A few observations:
1) It is emotionally difficult to terminate life support for a loved one, regardless of conversations held in advance.
2) Families need guidance from professionals who may not be well trained in managing end of life conversations.
3) Nurses may be better sources of information and support for families than physicians.
4) Patients and families need better information about their power to stop medical treatment that may not extend life and may lead to unnecessary suffering (e.g., my father did not get chemo following a diagnosis of lung cancer; his life expectancy was one year; he lived 2.5 years). I had access to clinical studies that gave me the estimate of his longevity and that drove my decision for quality of life. Too many physicians do not want to stop or withhold aggressive treatment. They need to practice slow medicine with elders especially.
5)The use of palliative care and hospice needs to be encouraged by medical professionals yet these conversations are best received when families have a relationship with the physician or a visiting nurse association.
I often speak in front of audiences about the aging journey and the need for advanced planning. My focus is on helping families prepare for their parents' last years. Do you offer programs for families or just for healthcare providers?
Dear Jan,
Thank you for your interest in the Schwartz Center. While we have conducted programs with patients in the past, at the present time we are focused on healthcare providers. However, we welcome the opportunity for patients and families to share their stories with us, as you have, through Bedside Manner and our Facebook community.
I agree with your observation that conversations at the end of life are never easy--and that's why families need guidance from professional caregivers. I recently served on a Massachusetts panel of experts whose goal was to identify best practices for end of life care and make recommendations to legislators and regulatory agencies. Yet individuals like yourself also make an impact by sharing your experience and wisdom. I hope you'll continue to share your insights on Bedside Manner.
Julie Rosen
Executive Director
The Schwartz Center for Compassionate Healthcare
Post a Comment