End of Life Care: Why Doctors Need Incentives to Talk With Patients

This week the Obama administration pulled back on a Medicare provision that would have compensated providers for discussing end-of-life care. The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law. This is unfortunate. The problem is that many people don't get the kind of care that they would choose for the end of life.

This happens because most doctors fail to raise the subject until patients are gravely ill. There are many reasons for this, including some physicians' -- even oncologists' -- discomfort with the topic of death and dying. Some fear diminishing their patients' confidence in their healing powers. Some cave, consciously or otherwise, to a conflict of interest: infusing chemotherapy is profitable; prescribing palliative home care is barely so, if at all

Many doctors are simply too busy to broach the subject before a patient becomes critically ill. If you have a waiting room full of people waiting to see you, it's hard to bring up a "what if" scenario and discuss a patient's wishes for the end-of-life in a thoughtful, not rushed way. The Medicare provision might have helped some people get the kind of end-of-life care they'd choose, instead of what's given automatically.

Meanwhile patients should be proactive about their preferences. If your doctor doesn't mention the subject of advanced directives, tell her what you want and put it in writing.

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