Whatcom View: Patients, families win if doctors paid to discuss end of life

The people of Whatcom County have an opportunity to impact federal policy on end of life care, and as the president of the Whatcom County Medical Society, I encourage you to take advantage of this opportunity.

We all have our version of what a medical nightmare might be. For me, it would be having a illness from which I had no hope of recovery, living in an institutional setting, being in pain, and being unable to speak for myself. Everyone has their own version of the nightmare. For some, the nightmare would be not being given a chance to survive a critical illness — even a small chance — in order to reach some milestone or life event. The point is, we are all different.

Very few patients — even patients with life threatening illness — discuss their wishes for life sustaining care with their physicians. When those discussions do take place, the physician is usually not reimbursed for it. Currently, Medicare only covers advance-care planning conversations in the “welcome to Medicare” introductory visit for new beneficiaries. Physicians face tremendous pressures in terms of performance, productivity, and other quality measures, and physicians are understandably reluctant to begin conversations that are often lengthy, difficult, emotional — and unreimbursed. Reimbursing those discussions would be an important step in improving end-of-life care for Americans.

I am a palliative care physician, and I practice at St. Joseph Hospital with the rest of my talented interdisciplinary team. We get involved when patients and families are facing serious illness, difficult-to-control symptoms, or tough medical decisions. The most heartbreaking cases are the ones in which a patient comes in critically ill and their loved ones have no idea what their loved one would have wanted. Within the last month alone, I have conducted at least five discussions with people who were in the last two weeks of their life who had never discussed their end-of-life wishes before. For some of these patients, it was too late for them have their dying wishes honored.

The literature indicates that when these conversations are timely and high quality, patients are more likely to have their wishes followed, and are more likely to die at home (where 85 percent of Medicare beneficiaries say they want to die). Families are more satisfied and less likely to have complicated grief reactions. When end-of-life wishes are unknown, patients are more likely to die in the hospital, and families are more likely to suffer anxiety, depression and post-traumatic stress disorder, often being haunted years later by whether they did the right thing.

The Center for Medicare and Medicaid Services put forward a proposal last week to reimburse doctors and other providers for discussions about end-of-life care. This measure has long been championed by health care and advocacy organizations, as well as by the influential Institute of Medicine in their 2014 report “Dying in America.”

Sarah Palin, the GOP’s 2008 vice presidential nominee, derailed a similar provision in by claiming that it would lead to “death panels,” which were never really explained but played to Orwellian fears of a world where all-powerful, government-run physician death panels decide who lives and who dies. Whether you are a Democrat, Republican or other, I hope you can agree with me that this distortion was one of the most nefarious political lies of recent political history. As of 2014, according to the New York Times, about one-third of people still believed that death panels are used in the United States.

We need to ensure that this important provision doesn’t get derailed again. The Center for Medicare and Medicaid Services is seeking public comments on the proposal until Sept. 8. The changes wouldn’t take effect until at least January. I am hoping that the good people of Whatcom County will join me in supporting this long overdue proposal by posting a public comment at cms.gov. You can also complete your own health care directive or get more information by contacting the Whatcom Alliance for Health Advancement at waha.org.


Dr. Bree Johnston is director of palliative care for PeaceHealth and president of the Whatcom County Medical Society.


Send your comments to Centers for Medicare and Medicaid Services, Department of Health and Human Services, CMS-1612-P 2, Attention: CMS-1631-P, P.O. Box 8013, Baltimore, Maryland, 21244-8013.