Tuesday, September 2, 2014

End of Life Conversations - Progress?

Much is being made of the AMA's recommendation to reimburse doctors for the time they take in having end-of-life discussions with their patients.  The recommendations appear to have a good chance of being covered by Medicare and certainly are a step in the right direction.  But will one conversation and the completed documents really work?  Well, like so many other situations - it depends!

How skilled is the medical provider in having the conversation?  What kind materials are shared?  Videos?  Pamphlets?  Web sites?  What's the follow up?  Are the loved ones involved?  And, most importantly, does completion of the documents really affect end of life care.  We only die once so we get no practice at this or being a critically ill patient.  So how will we really understand the choices and make sure they are known?

There is some data that advance directives don't work, at times aren't honored, well prepared, or even available when needed.

Respecting Choices has attacked the problem successfully and systematically and should be a guiding force showing us how to do advance care planning in an effective programmatic fashion.  On the home front, I've been involved in presenting programs in the community called "Your Life Your Choices".  This program lasts 90 minutes and is well received but only scratches the surface of the complex choices.

A single reimbursable visit for an end-of-life discussion is a good place to start - but much more is needed in order to have an organized way to provide the care that the patient understands and truly wants.  There are technology drivers in medicine that can put a lot of us the ICU on life support.  The conversation and the directives can help, but often aren't definitive.

The POLST form is the most definitive document, but isn't available in many states.  It basically puts your wishes into medical orders which are legal and binding.

So it is beneficial to pay doctors to have this 15 minute discussion and have documentation of the patient's wishes carried out.  But we need to avoid a hasty and mechanistic way of doing this.  The conversation is never easy, straightforward, or simple.  Lots of clarification and questions need to be addressed.  The systems like Respecting Choices (above) address this well.

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