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02/18/2017

Advance Care Planning and its Detractors

The default mode of our technologically advanced medicine is to use our technology. Nowhere is this more true than close to the end of life. And our technology is really impressive; with it, we can keep chests going up and down and hearts beating for a long, long time.

The troubling thing is that there are many people who would rather not have lots of machines keeping their bodies going, thank you, maybe you could just give me some oxygen and pain medicine and let me die at home with my family? But they never get a chance to talk about it with their doctors, mostly due to doctors’ lack of time or comfort in addressing such questions. And, unlike every other procedure in medicine, doctors don’t need your permission to do one of the most invasive procedures of all to you: CPR. Of course, CPR is generally performed on someone who is indisposed and unable to give their informed consent to the procedure. And CPR is often the first step on the technological path of ventilators, tubes, dialysis, medications to support the blood pressure, machines that keep the heart pumping, and all of those wonderful interventions that are life-saving when used appropriately and death-prolonging when used indiscriminately. Treatments that treat . . . nothing.

Ideally, doctors take time to discuss patient preferences about such treatments with patients and their families before the occasion to intervene arises; however, the factors noted above make such discussions rare. Those discussions are ideally an exploration of patient values and expectations from health care, and a translation of those values into appropriate medical interventions. They also identify people who are familiar with the patient and their values who can act as surrogate decision-makers should the patient not be able to make or express their own desires in a particular situation.

Because of the difficulties finding time for these important discussions, it was proposed as part of the Affordable Care Act (aka ACA, aka Obamacare) that Medicare reimburse doctors for the time they take to counsel patients and find out their preferences for end-of-life care. In an act of breathtaking rhetorical deception (aka lying), these discussions with patients, meant to elucidate their preferences for care, got labeled as “Death panels.” (I am not making this up.) The proposal was dropped from the ACA.

Then, in 2015, Medicare started reimbursing physicians for having The Conversation. But last month a Representative King introduced a bill in Congress, deceptively titled the “Protecting Life Until Natural Death Act,” which would revoke such payments.

Fortunately, the bill’s fate is “highly uncertain.” It should never see the light of Congressional day. It propagates the idiocy that lay behind the charges of “Death panels.” And rather than promoting “Natural Death,” it will lead to more people dying anything but a natural death; instead, they will be dying a technological death, hooked to lines and machines and drugs — things they would never have wanted or received had they only had a chance to talk it over with their doctor.

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