Should the government provide reimbursement for end of life education to the elderly?
Early in January, the U.S. Department of Health and Human Services (HHS) removed a plan within the health reform act to reimburse doctors for end of life discussions with Medicare patients. These discussions are continuing to be encouraged during routine annual physicals. The question that has captured a great deal of press lately is this: Should the government pay clinics for the time their nurses and doctors spend mentoring sick persons/families regarding complex end of life decisions, especially regarding the use of medical devices and services?
Many Christians answer “no” to this question. Their argument usually goes as follows: Talk and wisdom regarding choices of care and the use of technology at the end of life are matters of the spirit and/or faith community and not government. Government reimbursement will lead to abuse and overuse of the payment provision and turn this into another means of making a profit for the secular health care system. It will be impossible to trust the government and avoid the suspicion that the system is out to shorten the lives of sick persons either out of expediency or financial gain.
Answering “yes” to this question as a believer, family physician, and geriatrician seems easy: Gaining wisdom and guidance from social workers, chaplains, nurses, and doctors near the end of life is a huge public health issue. Seventy to eighty percent of us will die of a chronic illness and most of us, or our families, will be aware of our dying in the last two years of our life. We don’t want to die unprepared, lonely, and fearful.
I don’t want my physically fragile 91-year-old mother to arrive in the emergency room with chest pain and find that the normal protocol for acute coronary syndrome — including the potential for pacing, defibrillating, stenting, shocking, and intensive care rescuing — is applied unless that is not her choice. They won’t know without some planning and communicating on my mother’s part with her family that she has had diastolic heart failure for the last two years and is ready and willing to die, preferably surrounded by family who are as captivated by the mystery of the end of her life as she.
My mother’s faith is secure. She doesn’t want to die with a roomful of strangers and tubes in the intensive care unit. Doctors and others should be reimbursed for the time spent with those in the last quarter of life who wish to better understand treatment options for their life-limiting illness whether that be cancer, stroke, dementia, or heart, lung, and kidney failure.
Advanced care planning — a response to the inevitability of death
For the first 16 years of my career as a family doctor, I delivered babies and remember when prenatal classes came into vogue. I also recall the movement to make birthing personal, less clinical, and more understandable. The call now is to help persons understand and make the dying experience less clinical.
Henri Nouwen states this succinctly: “We have to prepare ourselves for our death with the same care and attention as our parents prepared themselves for our birth.” It is lamentable that Christian faith communities have not taken the lead in this educational process. Healing is a function of the church and only within that context to specially trained persons. The question really is where is the church leadership in this area to call together those specially trained persons within the context of the crucifixion and resurrection of the Messiah.
One of my colleagues recently described advanced care planning as a “roadmap that helps navigate through some otherwise pretty confusing terrain.” It is the process of helping you or me or our loved ones discuss future medical decisions and how beliefs, values, and goals may shape our future medical care.
The dying process has become very complex. Our culture encourages the mindset that what can be done should be done. We’ve become used to being fixed by the finest medical rescue system in the world.
Another colleague writes, “Physicians, being healers, continue to treat patients even though there may be no hope of recovery.” Likewise, many patients encourage the same approach with “an almost hysterical fear of illness and death.” Most of us don’t want to die, ignorant of what is happening as if there is no purpose. Advanced care planning can reduce the stress, bring common sense and realism back into the end of life process, and allow a spiritual dimension to what is happening that transcends the external event. I am thankful that I, as a physician and Christian can invite all who wish, to better approach the end of their lives with purpose, courage, and possibility. I lament the lack of Church leadership in this area
James K. Struve is a practicing physician at Bloomington Lake Clinic in Minneapolis, a medical director of Redeemer Health and Rehabilitation Center, and a member of Trinity Lutheran Church of Minnehaha Falls, Minneapolis.