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End of Life Care: Debating Reimbursement for Important Conversations

Posted Jan 05 2011 12:00am

There is a huge debate among politicians about whether CMS should reimburse physicians for discussing end-of life issues with their patients.  As you can imagine, these are serious conversations and they take a little planning and time.

I have something to say on this subject and will throw my voice into the debate.  I've worked in hospitals and healthcare for over thirty years and watched end-of-life processes play out in my own family with a great-grandparent, four grandparents and a few great aunts and uncles.  My wonderful father-in-law would be 106 if he were alive today and we just celebrated my mother-in-law's 97th birthday.

I've seen the impact that  hospice , palliative care , advance directives , Do-Not-Resuscitate (DNR) orders and thoughtful consideration of treatment options can have on individuals and their caregiver and I've written previously on  palliative care programs   and ethical issues related to end of life care

I also posted on a wonderful paper written by a physician addressing societal issues impacting our ability to  die in real peace .  As Dr. Gawande states in his New Yorker Article , "modern medicine is good at staving off death with aggressive interventions - and bad at knowing when to focus, instead, on improving the days that terminal patients have left."  This is in part a result of our payment system -- we provide incentives for our doctors to use expensive treatments and procedures, but nothing for those who want to have a conversation with their patient about what they want from their end of life care.

There is no one response to end-of-life care and the dying process for an individual, except for the fact that death will ultimately come one day.  Too often fear, lack of information and emotional responses are in the driver seat and this is why we see so much of CMS' budget being invested in the final days of life.  I for one feel that there is room for improvement and would prefer to see some of this money invested in healthcare earlier in a person's life and to help patients and families better prepare for the inevitable.

As I see it, we have two choices...

  1. government or payor organizations manage these decisions for us (real death panels implemented because of the unsustainable cost)
  2. individuals with their physician (who is reimbursed for his/her time) manage these decisions  

Which do you prefer?


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