An anesthesiologist described a chaotic scene in his hospital. Years ago, an elderly woman was rushed to the operating room with bowel trauma, septic shock and multi-system organ failure. The anesthesiologist, surgeon and nursing staff didn’t expect her to survive. Yet despite the slim odds, they did everything they could to save her. They were successful, but the patient paid a steep price. She was no longer able to communicate with her family.
Knowing that the woman had a terminal illness, and that each surgery worsened the quality of her life, her family decided to end all treatments. Just a few hours after doctors saved her life, the woman died without ever having the chance to say goodbye to her loved ones.
Scenes like this play out in hospitals around the country every day. In an emergency, physicians often don’t get the opportunity to talk to their patients about end-of-life care, or discuss how patients want to spend their last few hours. So they have no choice but to do everything they can.
This problem nearly had a solution. In 2009, lawmakers proposed HR 3200, a bill that would have reimbursed physicians for discussing end-of-life care plans with their patients. Even though a cardiovascular surgeon sponsored the bill and many doctors supported it, it became a source of political controversy.
Politician Sarah Palin claimed that the bill promoted “death panels” in hospitals. She said that patients “will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care.”
However, doctors say that this is not the case. In reality, the bill would have given patients more power over their medical decisions, not less. Every patient would have had the opportunity to tell their doctors how they wished to be cared for as they approached the end of life. For patients who valued quality of life over quantity of years, that might have meant forgoing invasive treatments altogether. For other patients who wanted to live as long as possible, no matter the cost, that might have meant using every life-saving option available.
In either case, the patient’s “level of productivity in society” was never up for discussion. In the end, the patients and their families would be the ones making the decision, not their doctors. The “death panels” didn’t exist.
Despite these facts, the bill failed to pass.
Medicare Rules Changed
But all is not lost for doctors and their patients. In October 2015, lawmakers passed a similar bill that allows Medicare to pay for end-of-life care consultations. Medicare now pays doctors $86 for the first 30 minutes of advance care planning in the doctor’s office, and $80 for the same service in the hospital.
Medical professionals say that the new Medicare law is important for their patients. It’s rare for doctors and patients to discuss end-of-life care, even when the patient has a terminal illness. This leaves doctors with the default position of doing everything they can to save their patients, even if it means that the patient’s quality of life will suffer. Sometimes, patients don’t feel comfortable speaking with their doctors about their plans. Other times, doctors simply don’t take the time to have these conversations or simply don’t know how to start them.
Changing the Face of Emergency Care
Take the anesthesiologist’s story about the elderly woman who nearly died of organ failure. He says that the family didn’t want her to suffer so much toward the end of her life. They were heartbroken when they discovered that they couldn’t communicate with her. Before she went to the operating room, she was still able to speak with the nursing staff. They, not her family, were the ones who heard her final words.
“We did what we had to do for her,” the anesthesiologist says. “I wish we could have done less.”
In the heat of a medical emergency, doctors have an obligation to help every patient survive unless the patient or family has given orders to the contrary. These often take the form of Do Not Resuscitate orders, or DNRs.
With the new Medicare rule in place, doctors have more incentive to discuss these important issues with patients before emergencies arise.
Rather than forcing families to make these difficult decisions at the last second, or exposing patients to a series of invasive medical procedures that the patient might not want, doctors now have a greater incentive to have these conversations early on. This could potentially save patients and families from making decisions under duress and lead to a more rational approach to end-of-life care.