As Jane Jankowski, DPS, LMSW discussed in her last AMBI blog posted on June 16, 2015, the proposed rule to reimburse providers for conversations with patients about advance care planning takes a positive step toward educating patients on end-of-life medical considerations by incentivizing doctors to take the time to address these issues in the clinical setting. Assuming that such reimbursements depend only on raising the topic of advance care planning with patients and not on the content of a patient’s choices (such as whether or not a patient chooses to forego treatment), encouraging health care providers to discuss health care decision making in advance with patients can go a long way to support patient autonomy and provide helpful guidance to surrogate decision-makers when a patient lacks capacity. Doctors often cite lack of time as a reason why they do not address advance directives in the clinical setting, but this rule would compensate doctors for their time, allowing them more flexibility in allocating time to address these issues. However, the proposed rule does nothing to ensure that the providers having these conversations are equipped with the proper tools and training to do so.
Advance directives, although they address the provision of medical treatments, are legal documents that can be complex and far-reaching, and therefore are not necessarily self-explanatory to patients or providers. Many states offer a statutory form advance directive as an example, but all too often these forms may be merely printed by a provider and given to patients to sign without sufficient explanation. These forms vary in their scope, but some sample living wills, such as forms from West Virginia and South Carolina, are little more than a declaration that no life-sustaining treatments should be provided. Other states, such as Michigan and Massachusetts, have no law giving legal recognition to living wills at all. It is possible that patients may be given forms such as these and not understand that they have the option to declare that they wish to receive particular life-sustaining treatments if they are terminally ill. It is also possible that patients who do not want to limit treatment will decline to sign any advance directive at all, believing that such documents serve only to support a decision to forego treatment at the end of life, and not a decision to receive some or all interventions. In such situations, merely starting the conversation may not be enough to help patients effectively articulate their wishes, whatever those wishes may be.
We don’t expect doctors to be legal scholars or trained bioethicists, but if they are the first ones raising the issue of advance care planning with their patients, they should approach these conversations with a sufficient understanding of the purpose and scope of advance directives to enable them to advise patients on making such decisions. Along with the expected increase in advance care planning conversations following any implementation of this proposed rule, there should also be an increase in educational opportunities for providers to learn more about advance directives and how to discuss them with patients. The bioethics community should support health care providers with continuing education on advance care planning and resources for providers to use in their practice, with the goal of improving physician-patient communication and empowering more patients to consider and articulate their wishes for end-of-life care.
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.