Atul Gawande, MD on Medicare Payment For End-Of-Life Counseling

In the wake of the Obama Administration’s retreat from allowing Medicare to pay physicians to counsel patients on their end-of-life options, here’s a short but powerful perspective by Atul Gawande, who wrote in depth last August in the New Yorker about how inadequate we are at helping patients negotiate death.

2 thoughts on “Atul Gawande, MD on Medicare Payment For End-Of-Life Counseling

  1. I agree that this is a red herring, but it is also a bit misplaced.
    Dr. Gawande, in both video clips, is discussing conversations with patients that have been diagnosed with terminal illness and are reaching a point were not much else can be done. These patients are not going to have annual physicals where their physician can add the end-of-life conversation to the bill. So whether the conversation occurs or not has nothing to do with the CMS regulation and it will not be paid for by Medicare anyway.
    Since CMS tied the conversation to annual physicals, it seems that the intent was to have the end-of-life discussion with healthy people, just to have something on file. An Advanced Directives form perhaps, in case of trauma or emergency, but not a decision on how to manage terminal disease in the final weeks or months. This is exactly what Dr. Gawande said this conversation is not supposed to be.

    Generally speaking, I don’t think Government should regulate the contents of conversations between physicians and patients (or anybody else), and I don’t think it should pay folks for presenting a particular subject to a customer.
    I do think that physicians have a moral and ethical obligation to discuss end-of-life with their patients at the appropriate time and I do believe that people have a right to end things on their own terms, but certain things should not be Government/payment driven.

  2. I think Margarit has a good point but I would like to think that bringing the discussion up before someone has taken a turn for the worse is desirable.

    I’ve had two relatives pass away recently and their Advanced Directives, written out long before they became ill, were useful to us. I was with one relative when she filled the directive out, and remembered that day when she checked the “no feeding tube, no ventilator” questions with a firm and decisive hand. That memory made the future decision not to do certain things easier for us because we knew we were making a decision that she wanted.

    In both cases the directive was filled out, not at a doctors’ office, but at a lawyers’ offices during estate paper signings. Could it be a bit easier to make these uncomfortable decisions in a setting where their reality is more remote? Perhaps we are asking the wrong profession to pose these uncomfortable questions to people.

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