February 21, 2017

An Ounce of Prevention

Kaiser Health News, one of the best sources of reporting about issues affecting older people, ran a story last week about the re-emergence of “death panel” agitation. Most of us thought this non-issue was dead, but apparently Representative Steve King of Iowa has decided that the decision by CMS to reimburse physicians for advance care planning discussions should be euthanized by Congress. Accordingly, he has introduced a bill called “Protecting Life Until Natural Death” with the explicit goal of instructing CMS to stop paying for conversations about the end of life. Which is too bad, since CMS just reported than in the first six months of 2016 alone, close to 14,000 clinicians billed for such discussions for 223,000 patients.

The irony is that the very idea of discussions by patients and their families about how they wish the end of life to unfold was spurred by a concern that patients aren’t being allowed to die a “natural death.” Instead, they have been forced to endure a technological death, death on a ventilator, in an ICU, while iatrogenesis-inducing medication is pumped in. In fact, as Representative King may or may not be aware, some physicians and ethicists advocate substituting the phrase “allow natural death” for the still oft-misinterpreted “do not resuscitate.”

There’s another reason that the proposed legislation is misguided. While advance care planning conversations are often advocated as a means of avoiding unwanted medical intervention near the end of life, they are better characterized as preventive medicine. Enabling people to talk about what matters to them and how they wish to be treated if they are very ill, approaching the end of life, and unable to speak for themselves, has the potential to ensure that patients are neither over-treated nor under-treated. It gives them the opportunity to state clearly and unambiguously that they would want to be put on a ventilator if they develop respiratory failure in the setting of advanced emphysema, however small the likelihood that they will be able to be weaned from the machine. It gives them the chance to say explicitly that they would want to be maintained with a feeding tube if they are in a persistent vegetative state, even if there is no chance of ever emerging from that condition.

What advance care planning does is to enhance patient choice. It doesn’t give government –or physicians, or health care surrogates, or families—the right to decide what treatment a patient will receive when he or she is dying. It assures that patients will make their own decisions about what kind and how much medical treatment they want. Surely that’s what Representative King wants for himself.

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