Ending life on your terms
The grown-ups are taking over in the debate about end-of-life care, writes syndicated columnist Froma Harrop.
The low point of the Obamacare debate — and there was much probing of the floor — had to be the “death panel” charge. It was the creepiest in a volley of lies aimed at killing health-care reform.
What was the fuss about? A proposal to pay doctors for time spent talking to patients about the kind of care they wanted in their last days. Such conversations would be entirely voluntary.
That was it. That was all. But “death panel” nonsense fueled so much hysteria that the end-of-life consultation benefit — and it is a benefit — was yanked out of the Affordable Care Act bill.
Fortunately, grown-ups are taking over. A new report for the Institute of Medicine, “Dying in America,” details the insanity that forces aggressive, often torturous, treatments on terminally ill patients who don’t want them — and at great expense besides.
Most Americans say they’d prefer to die at home, but the default in American medicine is to rush the gravely ill to the hospital. There, tubes are forced down throats and stopped hearts resuscitated with electric shocks.
“If you’re on a ventilator in an intensive care unit, you’re usually unable to die at home,” Dr. Edward Martin, head of the palliative care medicine program at Brown University, told me. “You’re likely to die in the hospital on the ventilator.”
That’s why you need to make your wishes clear in advance (even if you’re only 18). You might want every weapon in the medical arsenal thrown at sustaining your life. Or you might want to spend your final days peacefully at home or at a hospice facility, surrounded by loved ones.
An end-of-life talk with a doctor spells out the options. Patients can use it as a basis for filling out an advance care directive — a form listing which treatments they would want or not want. Of course, they may change their mind at any time. And in any case, as long as they can speak, the form is irrelevant.
The authors of “Dying in America” — doctors, insurers, clergy, lawyers, experts on aging, Republicans and Democrats — offer workarounds for the fringe politics that demonized advance care planning in the earlier health reforms. First off, they urge private insurers to cover end-of-life consultations, which many already do.
Several states offer this benefit for their Medicaid patients. The American Medical Association wants Medicare to follow suit.
The report calls on Congress to end the “perverse” financial incentives that rush fragile patients into invasive medical treatments they’d prefer to avoid. Better reimbursements for home health care is one suggestion.
Critics of end-of-life discussions argue the doctors would “push” patients to end their lives prematurely. Why would doctors do that? Where’s the financial incentive in losing a patient?
Meanwhile, there’s evidence that for some very ill people, a palliative approach may extend life longer than industrial-strength medicine. Palliative medicine seeks to prevent or reduce the symptoms of disease — such as pain, vomiting and impaired breathing — rather than seek a cure. For those expected to live six months or less, such care is often delivered by a hospice service, at home or in a facility.
Medical procedures come with risks that are especially high for those in rapidly deteriorating health. Thus, the risks may outweigh the possible benefits. In a study of terminal lung cancer patients, the group that chose hospice care actually lived three months longer than another subjected to hard chemotherapy.
Whenever you think that radical politics have totally tied up the country’s ability to fix the absurdities riddling our health-care system, you find gratifying examples of Americans just going ahead and making the repairs. Thankfully, end-of-life planning is becoming a routine part of American health care.