Friday, April 13, 2012

Family Medicine Activist: End of Life Discussions

Three patients over 80 years old were discussing end of life situations with me in recent months.  They, like many other seniors, are looking at their potential transition to "the hereafter".  They worry that it won't go well.  Loss of control is one of their concerns.  They have a living will and expect that it will protect them near the end of life.  Each has a daughter who knows of the living will and has health care power of attorney if my patient is incapacitated.

The Family Physician often has to introduce a discussion about the use of the living will and the DNRCC form during an appointment intended for a different purpose.  The patient does not schedule a separate appointment for this discussion, in spite of its extreme importance, ever.  There is no mechanism to be paid for the service.  We in the medical profession and patients and their families aren't yet effective enough to convince Congress to support payment for a focused visit for this purpose-advanced directives, aka end of life discussion.

Medicare includes hints about end of life discussion, but does not pay doctors for the service. "It remains legal for doctors to talk with patients during the annual Medicare visits; it's just that they can't be specifically paid for that discussion"....from Elder Law Answers web site.  So we're OK to have a very important discussion, but not able to get paid for the service, adding some frustration to intentions about end of life discussions.  

Another form they may need here in Ohio, now or later, is the Do Not Resuscitate Comfort Care form.  I like the simplicity and the list on page 2 of the form.  What do you think?  What happens in your state?

Ohio Do Not Resuscitate Forms


  1. I'm a daughter, who cared for her 87 yr mother, the DNR in place and had several conversations with her about it. It's 8 months past her death now, did I make the right decisions? Should I have insisted that hospice do something different? I followed her wishes but had no idea how hard it would be. I wish I could let it go.Stop 2nd guessing everything I did. Bet this discussion wouldn't be a paid for visit either.

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  3. I don't get why doctors think we can't be paid for having DNR discussions. The patient has a bad heart or cancer, for example. You spend 20 of the 30 minutes talking with the patient (and family) about managing the final stage of that disease which includes DNR discussion or other patient-driven limitations on intervention. That is disease-related counseling. It's at least a level 4 visit.
    Incidentally, I see the biggest patient/family discovery in these discussions is learning the reality that very often even if we do 'everything' it will not likely make much difference in survival and may worsen comfort.

  4. If we have any "Healthcare Improvement Act" scholars out there, I would gladly accept correction (I did not read the tome), but I believe it encourages end of life discussion in some fashion (payment?). In fact it was the lay press' misunderstanding of that clause that led talking heads to talk about "death panels".

  5. Tom,
    You are correct about the ability to have the discussion and billing for the problems, but it's sad that the discussion can't get "top billing" and we have to hide behind diseases instead of honoring death as a natural process. Death Certificates even have to be medically oriented listing a Medical cause of death on everyone (in Ohio). Old Age or Her Time Came doesn't cut it.
    Arthur, read the reference site I quote from in my post (Elder Law Answers)to see that they removed the part to which you refer because of the controversy.