Would you be more likely to outline your personal preferences for end-of-life care if you knew you would get paid for it?
A slew of new bills and recommendations are hoping to secure monetary compensation for both patients and doctors who agree to sit down and chat about advance health care directives—legal documents such as a living will, a do not resuscitate order (DNR) and health care power of attorney.
Two pieces of newly-introduced legislation—the "Medicare Choices Empowerment and Protection Act," championed by Senators Thomas Coburn (R-OK) and Chris Coons (D-DE), and the "Personalize Your Care Act," introduced by Congressman Earl Blumenauer (D-OR)—each contain a mandate to pay Medicare beneficiaries to outline their preferences for end-of-life care.
The Medicare Choices Empowerment and Protection Act instructs Medicare to give beneficiaries $50 for filling out a hard copy of their advance directives (or $75 for doing the paperwork online), while the Personalize Your Care Act would provide financial incentives for patients to review their end-of-life plans with their doctor every five years, or if their medical condition changes. Both bills have been referred to committee to await further conveyance.
At the same time, the American Medical Association (AMA) is soon expected to announce their recommendation that doctors who engage in advance care planning discussions with their patients be reimbursed by Medicare, Medicaid and other health insurance providers, according to The Pew Charitable Trusts.
The importance of end-of-life planning
About half of Americans over 60 have completed some form of advance directives.
Studies have shown that those who do outline a plan of action for their end-of-life care are less likely to die in a hospital and more likely to receive palliative and hospice care. The take home message appears clear: when aging adults take time to plan for their future, the goal of providing care shifts away from pure prolongation of life to enhancing the quality of life, however long it ends up being.
Unfortunately for the 50 percent without such guidance in place, their care is too often dictated by their doctors' individual style and the typical practices of the facility where they're receiving treatment, according to VJ Periyakoil, MD, Clinical Associate Professor of Medicine at Stanford University School of Medicine.
During the 2014 Meeting of the American Geriatrics Society, Periyakoil presented the findings of new study on how doctors view advance care directives. Overall, doctors in all specialties agreed that outlining end-of-life care preferences was an important step for elders to take. A whopping 88 percent of the physicians that were interviewed said they would sign a DNR for themselves, rather than undergo extreme life-prolonging treatment.
The doctors also claimed that knowing more about their patient's preferences would give them greater confidence to make decisions regarding that individual's care and such information would alleviate some of the worry over legal retaliation, should they limit that patient's treatment.
Why docs don't talk
Despite the widespread support of advance directives among doctors, there are a few factors that make end-of-life care conversations between physicians and their patients difficult.
For one thing, most insurance companies don't pay for special appointments to discuss advance directives (though some do), and there's little or no opportunity to squeeze in an extra conversation about such weighty issues during the typical 10-20 minute appointment window.
But not having enough time may actually only be a significant factor for a small fraction of physicians who decide to forgo having end-of-life care talks with their patients. A recent survey of doctors and nurses from the Mayo Clinic found a widespread lack of confidence among health care providers when it comes to bringing up advance directives. The providers' reluctance seemed to stem from a variety of misperceptions—patients and their families aren't ready to face these issues, end-of-life talks can quickly turn into end-of-hope talks, etc.
Many physicians and nurses don't receive formal training in how to approach patients and families about advance directives, which can contribute to this lack of confidence.
And when an elder has multiple doctors, there's often a sense of confusion over which one is responsible from bringing up end-of-life issues. "Communication is key, but in many hospitals and health systems this can be difficult," says Shannon Dunlay, MD, MS, a cardiologist with the Mayo Clinic in Rochester, Minnesota and lead author of the study. Dunlay emphasizes the need for health care providers to integrate such conversations into the ongoing care strategy of their patients, even if it means getting multiple doctors on the phone to discuss the plan. "Goals and preferences can change over time and patients and their families can feel more comfortable and confident in relaying their wishes to multiple providers," she says.