End-of-life discussions portrayed as first step toward death panels

Industry concerned that misinformation reflects negatively on hospice

"Stop the death panels" became a rallying cry for opponents of health care reform when one component of a bill was reimbursement for end-of-life planning discussions between physicians and patients.

Unfortunately for hospice providers and physicians, the reimbursement for end-of-life discussions is no longer part of the proposed bill under consideration, but more importantly, hospice leaders are concerned that discussions between patients and physicians have been portrayed negatively.

"This type of media attention increases the risk that people will associate end-of-life discussions and hospice care as something they don't want," says Deborah Jaques, executive director of the Oregon Hospice Association in Portland. A negative public portrayal of end-of-life discussions might cause individuals to hold back from having important discussions about the health care decisions they will make at different stages of their lives, she says. "Being able to ask yourself if hospice care will help you or a family member at some point in their life is critical to being able to make a well-informed health care decision," she says. "Although there is a saying that there is no such thing as bad publicity, I believe this is bad for our industry, because the negativity might prevent an individual from considering hospice when it might be the right decision."

The irony of the negative publicity is that the reimbursement was for a health care planning discussion to be held no more than every five years between a physician and a patient, says Jaques. "Many physicians already have these discussions with patients when they face changes in their health status, but there is no mechanism to reimburse the physician specifically for this type of consultation," she explains. Inclusion of specific reimbursement for a health care planning consultation would have increased the awareness of the importance of planning ahead, she adds.

Planning for care at different stages of life is common in Oregon, even without specific reimbursement for the consultation. Almost 80% of Oregonians have some sort of document that directs their health care decisions.1 Being able to think about how they want to live the last months or days of their lives enables people to consider hospice and learn more about the services that hospice provides, says Jacques. "In our state, 46% of all Medicare patients who die are in hospice care at the time of their death," she says. "This means that these patients are receiving care to minimize their pain, make them comfortable, and help their families through the process.

"It is also proven that hospice care saves money compared to patients who do not receive hospice care," says Jaques. A study by Duke University found that hospice care reduced Medicare costs by about $2,300 per patient, saving more than $2 billion per year, she says.2

POLST provides actionable orders

Although advance directives and living wills are important documents to designate health care representatives and indicate actions to take if certain situations occur, the document most often recommended for people who have a life threatening illness or are diagnosed as terminally ill, is a Physician Orders for Life-Sustaining Treatment (POLST), says Jaques.

"A POLST is an actionable, immediate physician's order that an EMT or emergency room physician can act upon," she explains. Even if the patient's wish is to limit life-sustaining treatment, the EMT is required to provide care in the absence of a physician's order, she says. "A POLST enables the EMT to follow the patient's wishes for treatment," Jaques adds.

POLST and living wills also are prevalent in La Crosse, WI, where 95% of senior citizens have a document designating their desires for health care at the end of life. This focus on advance care planning means more hospice care and less hospitalization while dying, which results in a significant savings. Medicare pays about $18,000 for the last two years of a beneficiary's life in La Crosse compared to nearly $64,000 for end-of-life care in Miami.3

The high rate of advance care planning is the result of a program that started in 1991 with leaders of the two local health systems agreeing to collaborate on an educational program that encouraged physicians, other providers, and seniors to have a conversation about health care wishes, says Bernard "Bud" Hammes, PhD, ethics consultant, director of medical humanities, and director of Respecting Choices, a community program to promote advance care planning, at Gundersen Lutheran Medical Foundation, La Crosse, WI. Not only did the city's two health systems agree to cooperate but as the program Respecting Choices developed, nursing homes, home care agencies, and hospices not affiliated with the health systems used the model to talk with patients and encourage conversations about advance care planning.

"We did not just focus on completing the document," Hammes points out. "We encouraged conversations between health care providers and patients, and patients and their family members." Physicians and other providers were taught how to facilitate a conversation that helps patients make informed decisions and weigh treatment options at different points in their health, he explains. "Timing is everything. You do not want to have a conversation about end-of-life decisions when a person's illness in under control," he says. "It is an ongoing process in which the physician or health care provider is constantly checking with the patient to see if the document should be updated."

After the provider talks with the patient, it is critical that the patient talk with family members to make sure that everyone understands the decisions and the reasons for those decisions, he adds.

Advance planning ensures patients and their families know all options available to them and saves money, Jaques says. Addition, quality of life at the end is enhanced, she says. "These are choices that we should want to make for ourselves, because the real issue is: 'What do you want to happen when you die?' because none of us is getting out of this alive," she says.

References

1. Tolle SW, Rosenfeld AG, Tilden VP, et al. Oregon's low in-hospital death rates: What determines where people die and satisfaction with decisions on place of death? Ann Int Med 1999; 130:681-685.

2. Taylor DH, Ostermann J, Van Houtven CH, et al. What length of hospice use maximizes reduction in medical expenditures near death in the U.S. Medicare program? Soc Sci Med 2007; 65:1,466-1,478.

3. Dartmouth Institute for Health Policy and Clinical Practice. Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008. Lebanon, NH; 2008.

Need More Information?

For more information about advance care planning, contact:

• Bernard "Bud" Hammes, PhD, Director of Medical Humanities and Director of Respecting Choices, Gundersen Lutheran Medical Foundation, 1900 South Ave., BG1-002, La Crosse, WI 54601. Telephone: (800) 848-5443 or (608) 775-8435. E-mail: BJHammes@gundluth.org.

• Deborah Jaques, Executive Director, Oregon Hospice Association, 812 S.W. 10th Ave., No. 204, Portland, OR 97205-2546. Telephone: (503) 228-2104. E-mail: jaques@oregonhospice.org.