Thursday, July 30, 2009

End of life care

One of the provisions in Obama's health care proposal is, apparently (I say apparently because I haven't read the provision in the original), that Medicare would pay for time spent in counseling patients on end of life decisions. Although I'm not sure why it's necessary to create a new CPT code, as there are already counseling codes that cover just about everything, on its face this is not a bad idea .

Wasteful interventions at the end of life are often driven by poor understanding of grandma's disease processes which leads to inflated treatment expectations. If given the appropriate information many patients and families would decide against expensive treatment options which carry little benefit.

In the current debate there's a misconception that the Obama plan would force all elders to undergo the counseling. DB called out that straw man in a post yesterday:

As I read the provision, physicians could charge for having these important conversations. Hopefully this provision will encourage physicians to address goals of treatment in patients facing the end of life.
Opponents have perverted this concept into claiming that the government will bully patients into forgoing “life saving” treatments. These opponents do not understand medicine or end of life care.

I agreed with pretty much everything in the post until DB dropped this bomb at the end:

So I say to the critics of this provision – shame on you. Any bill has much to criticize, but this provision stands beyond reproach.

Not so fast! Shouldn't we be thinking about all those unintended consequences, slippery slopes and conflicts of interest? While the pure notion of doctors counseling patients on end of life issues in a way that respects their wishes and values may be above reproach how does it play out in the real world of corrupt incentives? Perverse incentives to limit care have been with us for years in the form of the prospective payment system. Now we're going to pay very busy doctors to have these counseling sessions. Will they take the time to explain things in a way that the patient and family members will understand? Will values be respected? Will undue pressure be applied?

When looked at as a pay for performance measure the unintended consequences readily come to mind. I can see it now. Perfunctory conversations supplemented by pages of “smart text” in the EMR on end of life decisions. Opportunities for hospitalists to improve coding and limit hospital care all at the same time. A real win-win for administration.

Those considerations alone warrant debate on the provision. But it gets even more concerning when you consider that high level policy makers in the current administration are bent toward rationing directed against the elderly. I first pointed that out last May. More recently Retired Doc and Sandy Szwarc have weighed in and linked to this Lancet piece written by those policy makers. The double-talk below, in which the authors defend ageism in health policy, then explain why it's not really ageism, would be funny if it wasn't so chilling:

We consider several important objections to the complete lives system.

The complete lives system discriminates against older people. Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

So I'll conclude with this:

I do strongly agree that end of live discussions should be encouraged.
I do agree that palliative care teams play an important role.
I do not trust government policy makers and am concerned about the consequences, intended and unintended, of their actions.


Anonymous said...

As you haven't read the bill, I would urge you to read analyses from those who have and are experts on end of life discussions. For example:, Wesley Smith specifically addresses this question
here with some troubling findings in the language of the bill.
It's also important to recognize the agendas of groups that have positioned themselves as end of life experts and doing end of life education (groups he and medical ethicists have followed closely for years). Of course, they will likely become those counselors. This post provides an introduction.

Robert W Donnell said...

Thank you for your comment. I frequently enjoy reading Wesley Smith's blog and have a post in preparation which links to one of his. I will take a look at the two links you provided.

Anonymous said...

I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.