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End-of-Life Counseling Isn’t Just Good, It’s Essential

Posted Aug 27 2009 11:39pm

How did the idea that Medicare should pay for “end-of-life” counseling suddenly become such a hot button in the health care debate?  Because confused people seem to think that would lead to euthanasia. DefibiStock_000004161728Small

I’m not certain who planted that absurd idea in their heads, but it seems to be part of hysteria being whipped up by reform opponents. Too bad, because critics of the proposal such as Republican and House Minority Leader John Boehner are doing people a dreadful disservice by making them fearful of end-of-life counseling.

For one thing, Medicare already pays for this type of counseling. They just pay far too little for it.  So, is it better to have rushed end-of-life counseling or would you rather your doctor felt like this was something he or she could spend some time on?

My advice is spend as much time as you can. This is not about with-holding CPR just because you’re over 80.  It’s about telling your doctor whether or not you want to have a ventilator tube shoved down your throat if you are brain dead, or get knee surgery when you’re flat on your back dying of congestive heart disease.

It’s about deciding how much medicine is “enough” if someone is obviously dying.

Certainly, some people believe that life is so precious every conceivable effort should be made to protect it.  But unless you’ve worked in a hospital emergency room or ICU, you don’t have any idea of what could happen to you there. Technology has come a long long way, and the result can be very troubling.

That’s why people like physician and bioethicist Robert Martensen say it is crucial for anyone to at least have a living will: that says specifically which types of heroic measures you would like used to save your life and which you would not.  In this interview with NPR, Martensen points out that a doctor could spend one to two hours counseling a patient about all their alternatives during such a crisis.  Medicare, he says, pays $18 for that service in New York.

$18 dollars for some of the most important decisions that will ever be made about your life.  I think I’d vote “yes” to have them paid more than that.

In case you think everything that happens during the end-of-life is some kind of heroic measure aimed at making the patient more comfortable, or giving them another chance at life, think again. Sure, many amazing and wonderful things happen in ICU’s and emergency rooms.  We can all be greatful for the amazing work they do.  But there are also some unfortunate trends we need to be aware of as patients.

In his remarkable book “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era,” Martensen points out that Medicare pays very well for for ventilators, which means hospitals make more money by putting patients on them. In fact, a whole new type of medical facility has sprung up just housing patients on ventilators, he says:  “So these places which are usually concrete buildings by freeways house patients on these ventilators. And I think for some families this is fine, this is a kind of medical sanctuary, for others it’s a living tomb. The point that troubles me the most is that there very seldom is a candid discussion with the family or the patient – if the patient is alert, usually is not – about this extended kind of space, twilight zone of existence.”

Ventilators, he adds are just one way that doctors have of “artificially” extending life.  Kidney’s not working? You get dialysis.  Heart not pumping right? Here’s a pacemaker.  Can’t swallow? Here’s a g-tube.  It’s can be lifesaving, but it is artificial and the more of it you get, the less comfortable you may feel. If you want all of it, fine go ahead and ask for it. But if you don’t want it, save yourself a heap of suffering and make out a living will.

I recommend you ask your own hospital for their living will form and then go through it with your own physician.  If you’re not satisfied with his or her explanations, try to find someone else who is a health care professional who can explain it to you. But familiarize yourself with what living wills are before you sit down with anyone, that will help a lot. And go over your living will with your doctor and loved ones at least every two years.  Technology moves fast.

You can find free living will forms on the web.  Here are a couple useful sites:

Health Care Decisions

Mayo Clinic on Living Wills

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