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What End-of-Life Counseling Is Actually About

Joe Klein has a sensitive and serious post on the actual issues involved in end-of-life counseling. An excerpt:

I've spent quite a bit of time with my elderly parents--they're both 89 and have been together since the age of 5--trying to help them steer their way through some difficult decisions, and trying to guarantee that their decisions about the rest of their lives will be honored, even if they have lost the ability to announce those decisions themselves. This isn't easy. My mother and her two sisters are quite frail and entirely dependent on my father, who has made no specific plans about what should happen to them should he lose the ability to take care of them. He has a living will, he thinks. My mother has often said that if she becomes severely debilitated, "Just let me die." But I'm not sure she has made that clear in a legal document. My father is reluctant to talk about these sensitive subjects and has resisted signing a power of attorney, to be activated if he becomes incapacitated.

My father grew up during the Depression and like many of his peers, he doesn't like spending money on services he suspects are unnecessary. End-of-life counseling on issues like living wills and powers of attorney is something he could clearly use--from a skilled professional who, unlike me, knows the best way to describe these things and the easiest way to enact them--and he would be more likely to take advantage of this service if it were offered free-of-charge, and regularly updated, by Medicare. Although, even then, I have to admit I'm not sure he'd want to take advantage of it.

That last is an important point. The policy problem being addressed here is that Medicare doesn't specifically cover a meeting between you and your doctor to talk through these issues. That's what Blumenauer and Isakson and Lugar and Rockefeller and Collins are trying to change, albeit each in his or her own way.

By Ezra Klein  |  August 12, 2009; 5:29 PM ET
Categories:  Health Reform  
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Comments

I'm an oncologist. And I talk to my patients regularly about end of life issues. And these comments by Grassley and others are an insult to doctors and patients everywhere.

Earlier this evening, I spoke with a patient who is dying. I've known this patient for a long time. And in spite of many treatments we've tried for his cancer, nothing has been working. Today, we spoke about his illness, and he told me what he wanted. He told me that he's tired of coming to the emergency room, and he's tired of being admitted to the hospital. He told me that he wanted to be home for the remainder of his life. He told me that he didn't want to suffer. And he told me that he wanted to die peacefully, in his sleep. We spoke about this at length, and he asked me to enroll him in a hospice program.

People have a right to talk about their wishes at the end of life. This includes setting up health care proxies and advanced directives, exploring their wishes about resuscitation efforts, and discussing end-of-life care options such as hospice. It is the responsibility of doctors -- whether they are oncologists or cardiologists or primary care physicians -- to have these discussions with patients and their families. Such discussions ensure that an individual's wishes are respected at the end of life. Any physician will tell you that patients and their families benefit from these discussion. And they benefit whether these discussions occur over 10 years or 10 days.

We need to make it clear to everyone that this provision, as Joe Klein describes, does one single thing: it allows physicians to be compensated for having these discussions. These discussions happen anyway -- compensated or not. But they need to happen more. And perhaps one of the reasons they don' happen enough is that there is frequently no way for physicians to be reimbursed for them.

Doctors need to speak out against these unconscionable lies. We know the importance of end-of-life counseling. Many, many people -- like Joe Klein -- have spoken to their doctors about end of life issues as well. They should be speaking out as well. It is time that we stopped these awful lies.

Posted by: nwagle | August 12, 2009 7:16 PM | Report abuse

I would recommend that anyone who does not want invasive procedures done at the end of life (feeding tubes, etc.) make pre-arrangements with hospice care. They can manage pain and keep people comfortable when the end is near rather than trying to eek a few more painful weeks out of a broken body.

Posted by: bakho | August 12, 2009 8:32 PM | Report abuse

This is powerful and a breath of fresh air in a discussion that has grown distorted by ideological bias and blindness. We have to find a way to focus on the humane nature of the counseling that people need towards the end of their lives. People need this help, and their doctors can best provide it. They should be compensated for it so that it can more readily happen and so that they are reimbursed to at least a small degree for what must be a time consuming process.

Thanks to you all for posting.

Posted by: trulyb | August 12, 2009 8:56 PM | Report abuse

What a concept, individuals making informed choices about their care. How that can turned into "death panels" and forced euthanasia is something only the right wing crazies are good at doing.

Posted by: cmpnwtr | August 12, 2009 9:49 PM | Report abuse

These are great discussions. I understand some people just don't want to talk about it (thinking that maybe they won't die if they don't?).
My husband and I met with a lawyer after our first child was born to discuss all this and put it to paper. Honestly, it didn't occur to me to talk with a doctor, but I certainly would understand why one would.

Posted by: atlmom1234 | August 13, 2009 4:48 AM | Report abuse

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