THE NEW YEAR, MEDICARE & ADVANCE DIRECTIVES

In a Medicare policy taking effect January 1, the federal government will cover “voluntary advance care planning,” and pay doctors for end-of-life conversations with patients. This is smart, far-sighted and compassionate policy, and though it essentially is but one item in a schedule of payment rates for thousands of medical services, I’d like to think it will encourage better and earlier doctor-patient communication.

In this voluntary planning, patients can hear from the doctor about preparing an advance directive, which anticipates a time when the patient cannot make informed decisions and provides the care team with a clear sense of the patient’s wishes. The benefits should be obvious.

And yet news of the new policy has been simmering in the blogosphere and cable news over the holidays, and could heat up after New Year’s. It might be useful to remember, as an editorial in the Minnesota Star Tribune put it well: “Advocating end-of-life care planning does not equal end-of-life advocacy. That critical distinction is deliberately buried by irresponsible health care reform opponents in the long, ludicrous debate over nonexistent death panels.'’ (http://www.startribune.com/opinion/editorials/112575299.html)

Even for the best care-givers, conversations about the dying process are difficult, and yet they are crucially important to a patient in making smart and informed decisions. Often these topics are put off till close to the end, when there’s no longer any avoiding them, and when the patient has diminished comprehension. Care is best when the doctor clearly understands the patient’s wishes, and the patient understands what is possible and what is not.

Dr. Maria J. Silveira of the University of Michigan found in a study that many patients had “treatable, life-threatening conditions” but lacked decision-making capacity in their final days. The new Medicare coverage adds incentive for doctors to learn a patient’s wishes before a crisis occurs. Dr. Silveira told the NY Times she might ask a person with heart disease, “If you have another heart attack and your heart stops beating, would you want us to try to restart it?” A patient dying of emphysema might be asked, “Do you want to go on a breathing machine for the rest of your life?” And a patient with incurable cancer might be asked, “When the time comes, do you want us to use technology to try and delay your death?” (http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=2&_r=2&hp)

Oregon has engaged end-of-life issues as few states have, and Oregonians “understand that end of life planning is about keeping control of choices about life-sustaining treatment where it belongs -- with the individual, not with the government, physicians or hospitals.” ( http://www.oregonlive.com/opinion/index.ssf/2010/12/end_of_life_care_resuscitated.html)

With the new policy, patients gain knowledge and autonomy. Doctors get a nudge and an incentive to begin this conversation while the patient can still participate in it, and perhaps also improve their own communication skills.