End-of-life care provision stirs angst in health reform debate

The public outrage over reimbursement for patient counseling catches doctors by surprise but shows how delicate the discussion over advance-care planning can be.

By Kevin B. O’Reilly — Posted Aug. 24, 2009

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A relatively obscure provision in the House's massive health system reform legislation that would reimburse physicians for counseling Medicare patients about end-of-life care options came under intense fire from conservative opponents in August.

The political fallout prompted a group of six senators working on health system reform to drop the idea from ongoing negotiations. The House may follow suit when Congress reconvenes in early September, sources said.

But physicians said the controversy shows that despite decades of focus on helping patients choose what -- if any -- interventions they want as they die, end-of-life care remains a political and ethical tripwire.

Republicans, conservative commentators and boisterous activists at congressional town hall meetings condemned the provision, Section 1233 of HR 3200, as part of a larger plan to ration medical care.

In a post to her Facebook page, 2008 GOP vice presidential candidate Sarah Palin said the measure would place seniors before "death panels" who would decide what care they should receive.

The advance-care consultations eligible for Medicare reimbursement "are part of a bill whose stated purpose is 'to reduce the growth in health care spending,' " Palin wrote. "Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care?"

The American Medical Association, which supports HR 3200, tried to set the record straight.

"There has been a lot of misinformation about the advance-care planning provisions in the bill," AMA President J. James Rohack, MD, said in a statement. "Simply put, the bill would create a new Medicare benefit to pay physicians for time spent on advance-care planning consultations with seniors. It would be completely voluntary, and it will allow patients, if they wish, to discuss a broad range of issues, including hospice, living wills, advance directives and appropriate pain care.

"These are important discussions everyone should have so they are fully informed and can make their wishes known. That's not controversial, it's plain, old-fashioned patient-centered care."

Under the legislation, physicians could bill Medicare for advance-care planning consultations once every five years or when the patient's health conditions change dramatically. In states that have standardized life-sustaining treatment order forms, doctors could counsel patients about their choices and complete that documentation. The bill also calls for consensus standards on how to measure the quality of doctors' and hospitals' performances in carrying out patients' end-of-life care wishes.

Doctors dismayed

The political wildfire that flamed over a seemingly innocuous provision left many doctors and end-of-life care experts bewildered and dismayed.

"I'm disgusted," said Anthony L. Back, MD, professor of oncology at the University of Washington School of Medicine and an oncologist at the Fred Hutchinson Cancer Center, part of the Seattle Cancer Care Alliance. Dr. Back's research has focused on how to remove barriers that prevent doctors and patients from communicating about end-of-life care decisions.

Studies have shown that the 5% of Medicare patients who die each year account for 30% of Medicare's costs, with 78% of last-year-of-life expenses occurring in the month before death. A March 9 Archives of Internal Medicine study of 603 dying cancer patients at seven hospitals, oncology clinics and hospices found that care for patients who had end-of-life discussions with their physicians cost $1,295, compared with $2,780 for patients who did not have such talks.

Dr. Back said encouraging physicians to have extended counseling sessions with their patients through the Medicare system could help patients get the care they want at the end of their lives while saving the health system money.

"But," he added, "I don't see any meaningful public discussion about this going on at all. The whole issue is just politically unsalvageable."

Joseph W. Stubbs, MD, president of the American College of Physicians, agreed that the legislation's intent was mischaracterized by its opponents.

"The provisions in the HR 3200 legislation providing for payment to physicians for advance-care planning became a hook used by political ideologues," Dr. Stubbs said. "It's basically become an ideological war about what role government should play in terms of the personal lives of individuals and has little to do with advance-care planning."

Criticism of the measure has been "completely absurd," said Neil S. Wenger, MD, MPH, professor of medicine and director of the University of California, Los Angeles Health System Ethics Center. He was lead author of an August 2008 report to Congress on advance directives and advance-care planning that influenced the House provision.

"Advanced-care planning has been a recommended care process for several decades, especially for the last 10 or 15 years. For there to be concern that it some way violates people's rights, especially the most sick at whom it's actually aimed, is bizarre," Dr. Wenger said.

Some physicians, while reticent to echo the "death panel" rhetoric, did voice concern about the end-of-life care measure.

"I'm dubious about Congress getting into the specifics of how physicians should interact with their patients and how to plan in the case of someone who's terminally ill," said Mark Schiller, MD, a psychiatrist in the San Francisco Bay area and a board member of the Assn. of American Physicians and Surgeons, which opposes the Democratic reform plans. "That's just not the place of Congress."

Overall, though, the controversy signals a more universal problem. Americans are uncomfortable talking about end-of-life care and costs, Dr. Wenger said. "People are so afraid of this discussion that they can't even tolerate this occurring between one doctor and the patient, let alone at the societal level."

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Standardizing end-of-life decisions

Under the House's health system reform plan, doctors in states with standardized forms for life-sustaining treatments would be reimbursed for discussing such interventions with patients as part of an advance-care planning consultation. Eight states currently use the Physician Orders for Life-Sustaining Treatment form, and nearly two dozen others are developing programs to use the standardized order set. POLST documents whether patients or their surrogates want the following interventions under certain end-of-life circumstances:

  • Antibiotics
  • Artificially administered nutrition
  • Cardiac monitoring
  • Cardiopulmonary resuscitation
  • Cardioversion
  • Intravenous fluids
  • Intubation
  • Mechanical ventilation
  • Wound care

Source: "Physician Orders for Life-Sustaining Treatment," Oregon Health & Science University Center for Ethics in Health Care (link)

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External links

"Health care costs in the last week of life: Associations with end-of-life conversations," abstract, Archives of Internal Medicine, March 9 (link)

"Advance Directives and Advance Care Planning: Report to Congress," U.S. Dept. of Health and Human Services, August 2008 (link)

Sample "Physician Orders for Life-Sustaining Treatment" form, Oregon Health & Science University Center for Ethics in Health Care (link)

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