Q & A: Medicare and Advance Care Planning

Q: How does the absence of end-of-life discussions affect cancer patients covered under Medicare?

A: Getting Medicare payment for end-of-life discussions between patients, families and health professionals has not gone well.

When legislators and regulators tried to encourage these discussions and move to a more patient-centered culture, they were met with cries of “death panels.” The resulting firestorm of protests prompted lawmakers to withdraw the proposals.

As a physician, I can’t think of a more important subject. We doctors have less difficulty talking about diagnoses, treatments and procedures than we do about the prospect of further treatment offering little benefit and perhaps even causing more harm than good. Ultimately, it’s the patient’s wishes that count. If health care professionals don’t bring it up, how is the patient to know?

We have a culture in this country that is geared toward success. Many people believe the next miracle is just around the corner. Although miracles do happen, more often they don’t. This hope may rob patients of their last days—feeling ill from treatment and in the hospital instead of at home with family and friends.

Recent research has proven that early palliative care integrated with standard care for lung cancer patients receiving chemotherapy can actually prolong life. Palliative care specialists are comfortable with having these difficult discussions with their patients, whereas many oncologists and primary care physicians aren’t.

We tend to look death in the eye and say it won’t happen to us. But it will happen to us—all of us. Taking the time to talk with your family and your care team to let them know what you want done if you aren’t able to make a decision is just as important as having a discussion about your next surgery, radiation or chemotherapy treatment. I would go so far as to say it is more important because your opinions about your mortality will guide many of the decisions you make during your care.

Thinking about that question is not embracing a “death panel”—an insult to the many patients, families and physicians who have talked about their wishes and made those difficult choices.

Understanding what you want done—and how you choose to face your illness and its treatment—is good medicine, good care and good for you and your family.

—Len Lichtenfeld, MD, is deputy chief medical officer for the American Cancer Society.