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End-of-Life Discussions Should be a Given

As a physician living and practicing in Canada who has worked in a number of countries with universal health care systems, I found a recent article published in the New York Times, ironically humorous in the sad state of American Medicine that it portrayed. The title of the August 30, 2014 article, Coverage for End-of-Life Talks Gaining Ground started with the following quote: "Five years after it exploded into a political conflagration over 'death panels,' the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year." Many of us recall the absurd contention by Sarah Palin, the vice presidential Republican nominee that the government was planning "death panels," which would be tasked with which of our individual patients, including elders, would be allowed to get medical care or forgo it for budgetary reasons. As was written in Politico in June 26, 2012, Palin charged in an August 2009 Facebook post "that the Democrats' health care bill would empower a 'death panel' of government bureaucrats who can decide who lives or dies. The 2009 claim earned Palin Politifact's "Lie of the Year," but she said "that the president's health care law's Independent Payment Advisory Board makes life-or-death decisions."

Here we are in 2014, and very slowly and incrementally the American public and physicians in general and bureaucrats in the public and private sector are beginning to accept the medical benefits as well as the humanity and respect for individual dignity and autonomy in patient decision-making by supporting (and that usually means funding) discussions by physicians with their patients and often families about end-of-life wishes. In most jurisdictions where the negative stigma of end-of-life planning has been overcome and what is often in the professional circles is called advance-care-planning exists and is supported, there is ample evidence that it serves patients, their families and physicians and allied healthcare professionals well.

I have not practiced for many decades in the United States but have had to deal with American family members going through end-of-life situations and although not many, I was not overly impressed with the important transformative leap from invasive and technologically prioritized treatments to palliative care philosophy-based decisional options. In Ontario, Canada, in contrast with where I currently work and have done so for many years in both geriatric medicine and palliative care domains, the active discussions about advance care planning and end-of-life preferences and options are ubiquitous and supported by billing codes for such communications with patients and families.

In my office, a large percentage of my patients have cognitive impairment and are therefore accompanied in most visits by one family member or more. I have found among the many discussions that I have with patients and their families related to the "future" and their wishes I use the following little scenario: I ask the patient if they like ice cream, to which invariably the answer is yes. To personalize the discussion, I then follow with something like "what flavor is your favorite?" After I receive the answer I then ask, "so how would you feel if you could never taste ice cream again, and for that matter never taste anything again? In fact you will not even know if you are eating because there would be a tube in your stomach into which something called a feed—not food as you know it—goes. How would you feel about that? Is it something you might wish for?"

After many such encounters the vast majority of answers are something along the lines of, "that is nothing I would want." Or, "who would want that?" I then may follow with, "but what if it meant you might not be able to live unless it is done?" to which I usually get back, "but life would not be worth much without being able to taste food, would it?" On rare occasions, I have someone who says something like, "well, it depends" or something like, "it will be left to God's will or whatever the doctors say," but more times than not the idea is rejected quite handily.

I then tell that family that this is just the beginning of what should be conversations about advance care planning that they and I over time can use to determine what the preferences might be should something happen. Some families say that they have had those discussions, and some say they want to have them but do not know how to start, which leaves an opening for me as a physician to pursue the main categories of advance care planning and end-of-life decision-making talks. They do not have to take lots of time and often it is better to do them piecemeal depending on the cognitive status of the patient.

The most important message is that these conversations are crucial and I see that played out when patients are admitted to the palliative care unit where most of them, although not all, understand what the stakes are, and are prepared to make the best along with the dedication of the health care professional staff to the focus on symptom management and psycho-social issues rather than being mesmerized by elusive technological treatments during this last period of life. And to refer back to the apparently novel component of this in the American Health Care environment, I and other physicians are reimbursed for the time and effort that goes into these discussions. There are codes in the fee-for-service billing manual for those physician who are not practicing under salaried arrangements, that delineate the time period for discussion blocks and the billing codes and amounts that can be billed. These codes are generally noted in the health care record and when submitted to the health insurance plan for reimbursement the diagnostic code is listed (ie, Dementia, Cancer, end stage heart failure), the meeting or counselling session with patient code and the block of time allotted—and that it is—the payment comes along with all the reimbursements for clinical care provided.

This is the contemporary standard of practice in this century—it must be unless you believe in immortality. Modern medicine has many "tricks" up its ever-expanding sleeve of treatments. This was dramatically described in an opinion piece in the September 7, 2014 review section of the New York Times. Theresa Brown describes the almost tragic results when physicians are so focused on the latest technology available and thereby lose sight of the importance of a death that is not due to a lack of some new medical wizardry but the nature of all things mortal. Her article, "When It's the Doctor Who Can't Let Go" captures the difficulty some physicians experience when they have to let their patients choose some closure in medical treatment and opt for comfort rather than another short-term usually elusive "cure."

We, as physicians, must help our patients and their families know when it is time to say enough and to prepare for that moment not in the midst of a crises but when the mind is working calmly and one's values and wishes can be interpreted and then documented for future reference so that the end of one`s life is as dignified and supported medically with proper symptomatic care as possible.

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