Editorial: Helping Patients and Doctors Talk About Death

Medicare announced plans this month to reimburse doctors for talking with patients about what treatments they want — and don’t want — toward the end of life. This sensible, long-overdue proposal is likely to have a very wide impact. About 80 percent of people who die in the United States each year are covered by Medicare, and Medicare policies are often followed by private insurers, some of which already pay for these advance-planning conversations. 

The need for such talks was made even clearer by disturbing new evidence in a study in the July 9 issue of JAMA Oncology, a journal of the American Medical Association, that many cancer patients, who often face difficult choices over whether to have chemotherapy or radiation, don’t receive the care they want at the end of life. 

Researchers at the Johns Hopkins School of Medicine in Baltimore used a national survey containing exit interviews with the next of kin of nearly 2,000 cancer patients who died between 2000 and 2012. Patients who had end-of-life discussions with doctors and those who created living wills, which describe the kind of care a person should receive, were most able to avoid having treatments that they did not want imposed on them. Patients who relied solely on designated health care proxies to make decisions if they were incapacitated were often subjected to aggressive last-minute care. 

The lesson seems clear. End-of-life discussions involving all parties — doctors, patients and surrogates — are crucial to ensure that people’s preferences are specified and understood by everybody. 

Medicare’s proposal, which is part of the agency’s physician fee schedules for 2016, was welcomed by major medical organizations but faces opposition from right-to-life and disability rights groups that say advance-care planning persuades people to reject lifesaving treatment. The talks, however, are voluntary, and many patients and families are eager to have them. 

The payment rates for doctors and other health professionals who meet with patients about end-of-life care will be decided by Nov. 1, when the plan is expected to become final. Virtually all experts agree that medical professionals will need additional training. Many doctors are uncomfortable talking to patients about planning for death. 

The proposal would end further delays on an important issue. In 2009, a similar plan was floated to pay for end-of-life discussions under the Affordable Care Act only to be derailed by Sarah Palin’s bogus cry about “death panels” that would cut off care for helpless patients. In 2010, Medicare tried to pay for voluntary advance care planning as part of annual wellness visits only to have its efforts overturned by similar political pressure. This year the opposition seems more muted, and more patients may finally be able to talk to their doctors and gain more control over the care they receive in their final days. 

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