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Let’s talk about your “End-of-Life,” says AMA

Let’s talk about your “End-of-Life,” says AMA

Will Medicare follow the example of private insurers?

The American Medical Association wants to jumpstart a health care discussion that died a political death almost five years ago: to “death panel,” or not to “death panel?”

Of course, we’re not talking about actual panels making life-or-death decisions on behalf of patients, but mandated coverage for “end of life discussions” between patients and doctors. Back in 2009, Sarah Palin coined the divisive term, and woke America up to the possibility that yes, handing over our health care decisions to the government a little bit at a time could backfire in spectacular and inhumane ways.

The New York Times reports that the AMA is putting pressure on the Center for Medicare and Medicaid Services to begin covering these end of life discussions. If the Center adopts the AMA’s recommendations, Medicare patients could start receiving coverage for these conversations as early as next year.

From the Times:

“We think it’s really important to incentivize this kind of care,” said Dr. Barbara Levy, chairwoman of the A.M.A. committee that submits reimbursement recommendations to Medicare. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”

Now, some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician here in Dundee, wants to avoid situations in which he has had to decide for incapacitated patients who had no family or stated preferences.

Although the Affordable Care Act contains no coverage requirements for end of life conversations, many private insurance companies have made the choice on their own to cover these appointments.

If asked to describe the conservative position on health care in one word, I would go with “choice.” I believe that patients should be able to choose whether or not to have these conversations with their doctor, and I believe that they are just as important as office visits spent diagnosing strep throat, or cancer, or those spent arranging post-surgical pain management. For some, end of life considerations only come when their life, or the life of a spouse or child, is in danger. To automatically dismiss these private conversations between doctor and patient as an unacceptable norm in American health care is disingenuous; however, ignoring the slow(ish) creep of government control over our bodies is equally so.

In an article from National Review, Wesley Smith makes an important point:

Doctor and patient discuss what should or should not be done. Patient’s condition improves or worsens. Often, that will spark another conversation–and then another. Now, if insurers want to pay for this, fine with me. If Medicare pays for it, fine too–depending on the details.

Details are so important when it comes to actual policy implementation. I don’t think that it will be productive if conservatives who are invested in this battle to keep the government out of our health care decisions immediately drag us all back into last decade’s debate. This year’s debate should focus on the level of government intervention that can (and most likely will, if the ACA goes the way of the NHS) come between a patient and his doctor when the government gets to decide how long the horrible conversations about feeding tubes, ventilators, and “extraordinary measures” should last.

Progressives tend to obsess over the sanctity of the body against invasive government action. Feminist overtones (set very far) aside, conservatives should adopt this same obsession—it’s my body, my choice, and my conversation with my doctor about how I want to spend my last moments on Earth. This reborn conversation about end of life coverage is inevitable, and how we address the issue is crucial to regaining and maintaining autonomy in our health choices. Avik Roy’s 2010 article on the issue remains prescient:

It comes down to this: if the government is funding health care, and simultaneously funding end-of-life counseling, the government has a conflict of interest. The government has a financial incentive to encourage people to “pull the plug on granny,” regardless of whether or not that is consistent with granny’s, or her family’s, wishes. It is, at bottom, the same reason we insist on a free, independent press (and free speech in general): when the government controls the media, it has a conflict of interest; i.e., an incentive to promote journalism that is favorable to the government.

The message is clear: leave my body alone. My doctor and I have it covered.

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Comments

I don’t know why you refer to Sarah Palin’s “death panel” term as “divisive.” Shouldn’t we use the term? You admit, and Avik Roy’s article admit that there’s a real possibility that the gov will one day be deciding when to pull the plug. Leftists, e.g., Krugman, Dean, and Rattner, admit that this will be necessary (see http://www.breitbart.com/Big-Government/2014/08/31/Feds-May-Reimburse-Medicare-End-of-Life-Discussions-After-Mocking-Palin-s-Death-Panels ). Quoting Rattner, “We need death panels …” If the left is willing to be so clear about exterminating the unfit, why shouldn’t we call them “death panels?”

And it’s not just leftist advocates chiming in. The Dear Leader himself said that sometimes you just have to give grandma a pill. In case it doesn’t register: the leader of the free world is interjecting himself into your life-and-death decisions. Nowhere in the Constitution does the gov derive such a position. This is the eugenic socialist agenda taking over our freedoms.

The AMA is a disgusting organization. Doctors are supposed to heal, but now they want the gov’t to pay them to talk us into dying. Talk about conflict of interest! You can’t even trust your own physician anymore.

The bottom line is, if we don’t scream about death panels now, we’re bound to suffer with them sooner or later.

This is “medical treatment”? Physicians want additional payment for answering questions that arise and should be answered in the ordinary course?

(Can lawyers also bill Medicare for these conversations? Lawyers draft advance directives and living wills long before it’s time for a DNR — do not rescusitate — order, which is not about withdrawing tubes, ventilators, etc. already in place, but an order for non-physicians such as paramedics.)

Will you PLEASE get it straight? The “death panels” are NOT the “end of life” DISCUSSION one might have with a provider. The DEATH PANEL is the “IPAB” Independent Payment Advisory Board. And the IPAB is NOT going to judge whether Aunt Sally should get her pacemaker or not. They are going to make POLICY decisions like “No pacemakers for anyone over 73 years and 6 months of age” as adjusted for what the SOCIALIZED MEDICINE REGIME can AFFORD! And this will be a continuation of the ONE SIZE FITS ALL SOCIALIST AGENDA! Unless of course you are a friend of the current ruling junta. Remember the IPAB is a copy of the ENGLISH SYSTEM whereby patients too “old” or too “young” to be of use to the STATE die off from LACK OF CARE! See “Patients starve and die of thirst on hospital wards” http://www.telegraph.co.uk/health/healthnews/9591814/Patients-starve-and-die-of-thirst-on-hospital-wards.html

    Will you PLEASE get it straight? The “death panels” are NOT the “end of life” DISCUSSION one might have with a provider.

    I believe you are making a distinction without a difference. This is about the gov’t interjecting itself into “end of life” decisions, decisions that have always been a private matter. By injecting money, they are buying a stake in the outcomes of these decisions. It will inevitably be tied to the IPAB regulations by influencing patients to be good little commies and go out with dignity. Hence, this money move must be tarred as part of the death panels, for they are inexorably linked.

definitive Conservative point. People can talk to their own doctors on their own dime. the Elderly have had a lifetime to save for their end of life care, they can pay for it or have their kids pay for it. Leave me out of it.

Removing choice from the healthcare marketplace is evidenced by the parents of a 5 year old English boy now incarcerated in a Spanish prison under threat of extradition to the UK for “child neglect” because they dared to remove their son to Spain to obtain a particular targeted radiation therapy that is unavailable on UK’s NHS until 2018. This is what occurs when bureaucracy intercedes in patient healthcare relationship. Repeal ACA now!

I’m a physician. I’m in academic practice where I care for patients with end stage lung disease and with ALS. My thoughts —

1) Sarah Palin was and is right. The Democrats were indeed trying to sneak death panels into ObamaCare, and she correctly called them on it.

2) Wesley Smith at NR also is right. It is fine for Medicare to pay for consultation, depending on the details.

3) We need more consultation and discussion on end-of-life discussion. Those discussions should be initiated by medical professionals with patients and their families, should be confidential, without outside pressure, and with a single agenda — what is best for a patient given the medical circumstances? The focus should be on educating the patient and family on the natural outcome of the end-stage disease, the specific issues involved, the appropriateness of comfort (as opposed to life-sustaining) care, and the ultimate futility of aggressive life-sustaining care.

I have had hundreds — hundreds — of these conversations, and have supervised medical residents/fellows in many. Patients and families often times want these and want more. I’ve had very few interactions that turned out badly. I’ve never once pushed any agenda other than the single one: what is best for the patient.

Recognize that of course we all go through the class stages of grief in death and dying. Care providers need some training in how to make these conversations effective and useful — it’s not something you pick up on the fly.

I welcome the exploration of having Medicare provide a specific CPT code for “end of life consultation”. Just don’t set an agenda other than what is best for the patient.

    That’s the rub, when someone else is putting down the money then they get a say, like it or not.

    A childless couple gets to vote on the school board, gets a say in the curriculum, and if active enough pretty much can exert a lot of influence on the system that they pay into but don’t get anything out of.

    This will not end well especially when the source of money and the “customers” are completely disconnected. There is nothing in this life that is truly free.

I’d like to see a lot of informed discussion of this subject prior to individual consultation with our physicians. A group setting with professionals explaining what is involved in various aspects of end of life care could be helpful for many who aren’t that familiar with hospitalizations and alternatives. I would add discussion of organ and tissue donation, and the importance of family members being aware of all our wishes. (My parents mailing copies of their advance directives to each of us, was perhaps not the best way broach the subject, so I’ve been a little more vocal.)

It’s also important to know family availability and limitations and exactly what professional resources are available locally, particularly if in-home comfort care is desired.

This article presents a libertarian argument. It is not a conservative argument. It is definitely not a Christian argument.

From the Christian point of view, our bodies do not belong to us – they belong to God. We are not allowed to do whatever we want with them.

The religion of unfettered choice is not Christianity.

The classical view of freedom is not the ability to do whatever we want whenever we want. It is the conforming of our lives to reality – that is God’s moral law and his purposes for us.

    Shane in reply to gibbie. | September 1, 2014 at 7:37 pm

    But even Jesus let us know that the conforming our lives to reality comes with hard lessons because we are stubborn and arrogant. He said that we should not be stumbling blocks for the little ones and he also gave us the parable of the prodigal son.

    Even Christians need to let others find their own way to God (or not).

Part of the problem here is with the computerized tracking and billing of everything doctors do. MD’s now have to account for every minute they are with a patient and enter billing codes into a computer for everything.

But there was no billing code for the time a doctor might spend discussing do-not-resuscitate orders or organ-donation options with a patient. This provides codes for the computer systems which will allow MD’s to get paid for the time they spend talking about these things.

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