A recent Medicare funding controversy has brought new focus on the need for all adults, no matter their age, to have conversations with their families and their doctor about end-of-life care.
"Before I offer treatment, I need to understand their wishes," said Dr. Charles Stinson, medical director of the Forsyth Medical Center palliative care unit.
Some patients, he said, want to be allowed to die comfortably if they are living on a respirator or unconscious, while others want to prolong life as long as possible.
Beginning Jan. 1, a doctor could be paid by Medicare for having a discussion with his or her patient about their end-of-life choices during their annual wellness visit. But after heated political debate, led by Sarah Palin, who said the ruling and other health-care initiatives would allow government "death panels" to decide who lives and who dies, the Obama administration pulled the funding from Medicare law less than a week after it became effective.
The North Carolina Medical Society and doctors such as Stinson lament the loss of funding.
"These conversations can take up to an hour," Stinson said. "If I had had that permission from Medicare to spend that time in counseling, that was very exciting for me. These conversations cannot be rushed."
Melanie Phelps, deputy general counsel for the N.C. Medical Society, agreed.
"This is not something that takes two minutes to go over," she said. "It is the position of the medical society that it is very important for patients to express their wishes for end-of-life care, not only to their doctors, but to their families."
Nothing prevents the doctor from having these conversations anyway, and most doctors will do this, but the Medicare funding "would have allowed more time" for the discussion, Phelps said.
Given that doctors usually see patients for about 15 minutes, a 30-minute conversation about end-of-life care is the equivalent of two reimbursable visits, she said.
In the absence of a patient's advance directive, which states his or her plan for end-of-life care, the default mode of doctors and hospitals is to aggressively treat patients, sometimes meaning long stays in intensive care during which the patient is unconscious, kept alive by a respirator and being fed only intravenously.
But the political debate scared some elderly people into thinking that the reimbursable plan was meant to limit their choices about end-of-life care. Some said the government promoted the conversations to try to reduce Medicare costs, citing the $55 billion paid by Medicare last year for doctors' and hospital bills in the last two months of the patients' lives.
Doctors said the opposite is actually true — that the conversations allow the patient to better dictate his or her wishes.
With the conversations, and with advance-directive documents, "the patient is the decision maker," Stinson said.
Don Dalton, spokesman for the North Carolina Hospital Association, said his organization encourages hospitals to pay close attention to end-of-life care issues.
"While the hospital association recognizes the value of end-of-life planning, this issue has currently evolved into the political arena, and we don't have a position on this issue," Dalton said.
Administrators and doctors at the Wake Forest University Baptist Medical Center declined to comment, with a spokesman saying, "There is just too much uncertainty with the current health reform."
Stinson said the issue should not be political and that the most important thing is for a doctor to hear his or her patients' wishes.
"Most of my patients tell me that what's important to them is to be comfortable, maintain dignity and spend what time is left with their families," he said. "I also hear that they want to be spiritually at peace."
Most patients also tell him that if the life-prolonging treatment won't help them get better, then they don't want their lives to be maintained artificially, he said.
"But others say, 'I want to live as long as possible,'" he said. "My goal is to give them information to have them make an informed choice, and only to provide whatever care is their wish. It is such a gift to us doctors to have their voice completely understood."
afuller@wsjournal.com
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