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Resuscitate End-of-Life Counseling

The level of passionate debate � on both sides � over the House health care reform bill provisions to make advance care planning consultations available to Medicare beneficiaries has been the product of strongly held convictions to be sure.[IMGCAP(1)] In the end, the difficult reality of end-of-life decisions and objective thinking prevailed over the hyperbole of ³death panels² and government-encouraged euthanasia.The decisions are no less painful for those on Medicare than for those who are not. Each is entitled to the empathy, guidance and care they wish to avail themselves of at one of life�s most traumatic times. All of that rhetoric, however, had a negative effect and could ultimately deprive those who want particular care � when they need it the most � at the end of their lives. Unfortunately, the emotionally charged debate persuaded the Senate Finance Committee to forgo any provision for such voluntary end-of-life consultations in the Senate�s version of health care reform. Nonetheless it�s likely that a final House bill will include advance care planning consultations. In the end, it will be up to a House-Senate conference committee to decide the scope of that provision of the bill. That is why it�s essential to resuscitate this issue now and insist that it remain a vital part of health care reform.The reality of health care today is that seniors do not know all of their options when faced with serious, chronic medical conditions. Few family members or friends have the expertise and knowledge to advise them and almost no experts will provide advice and counsel without compensation.Doctors often have no idea about their patients� care goals. As a result, care is often dictated by those who have not spoken directly with the patient.That�s the problem addressed by the advance care planning consultations provision. The opportunity for such consultations � which are voluntary, not mandatory � ensures that elderly patients facing difficult decisions are well-advised of all options and the individual�s well-informed wishes, goals of care, and values are known and honored by their health care providers.This is a patients � rights issue.Health care providers benefit, too. They need to know who to contact when a patient loses the capacity to make health care decisions. When a patient chooses and authorizes a spokesperson, through a health care power of attorney, physicians can provide health care consistent with the patient�s goals and wishes. Patients can include any specific wishes or guidance for health care in this kind of advance directive.Not surprisingly, research tells us that patients prefer to have their doctors initiate these talks. When physicians do so, patients are more satisfied with their care. The failure of physicians to initiate discussions in connection with serious chronic illnesses is often associated with poorer patient quality of life. For Medicare patients with serious, life-limiting conditions, these consultations are a win-win situation. They enhance patients� rights, comfort and quality of care.There is also some evidence that consultations may have a cost-saving impact. When you give seniors comprehensive information about their care options as they approach the end of life, many choose care that will improve the quality of remaining life, rather than more aggressive treatments that may extend life but reduce its quality and comfort. Such advance care planning consultations are intensely personal and must be made only after a patient is fully advised of the options.The American Bar Association has actively encouraged all adults to engage in health care advance planning for more than 25 years. This proposal, if kept alive in any final version of health care reform, significantly moves patient care in that direction. It deserves the support of anyone who wants patients� voices to be well-informed, heard and honored.Carolyn B. Lamm is president of the American Bar Association.