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Monday, December 27, 2010

Narrative Reboot

Yep, it's back:

Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

While the new law does not mention advance care planning, the Obama administration has been able to achieve its policy goal through the regulation-writing process, a strategy that could become more prevalent in the next two years as the president deals with a strengthened Republican opposition in Congress.

Look for Sarah Palin's ghost-writer for her Facebook status updates to claim some form of ham-fisted vindication within the coming hours.

The only problem is that one of the modern conservative movements top bloggers - and Palin cheerleader - actually agrees with this idea.

There is nothing wrong with patients planning for contingencies through advance directives. There is also nothing wrong with doctors discussing those options with patients ahead of those decisions. As the spouse of a patient who has faced life-threatening circumstances on more than one occasion, I certainly understand why these conversations need to take place before the pressures of acute circumstances come into play. This new regulatory effort at least puts the conversation where it belongs, in routine wellness visits, rather than as a five-year set conversation. It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.

While Ed Morrissey does refer back to his talking points memo and express "concern" over the fact that there will be "incentives" to doctors to encourage end-of-life counselling sessions, one has to wonder why doctors wouldn't immediately do this on their own without dangling a metaphorical carrot in front of their nose.

I can clearly recall the moment when my uncle was told that he would not survive the cancer that had taken over his entire digestive system. Up until then, there had been limited conversations regarding what could happen, what treatments were available, and what the consequences were. That was left out of the "doctor patient conversation" until it was ultimately too late.


Have we entered a time and place where the part of the Hippocratic Oath to "first do no harm" has a payment prerequisite? It would seem so.

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