The AMA has 7,800 codes for all types of medical services. Discussion of end-of-life care has been considered part of routine primary care. Now, the medical-industrial-complex wants another fee for the service of discussing this topic.
The service in question is “Advance Care Planning“. Certainly, a good idea — a health care provider should be talking with patients about end of life issues. We all die, that seems obvious, but someone should ask: “when it does happen where do you want to be, who would you like to be there, and have you told someone about your wishes for medical care at the end?”
Virtually anybody can ask those simple questions. Sure, getting up the nerve to ask the questions is hard for family members. And, sometimes there is no family to discuss the questions or the answers. Like other issues of health care, the primary care provider should broach the questions and record the answers and facilitate discussions with the people close to the patient. It’s not a question that needs repeating at every visit, but periodically as conditions change. Is the discussion important? Absolutely. Soap operas are not where the answers exist.
There is an undercurrent of distrust. The distrust is because the medical profession seems so motivated by profit they may do unnecessary treatments when death is near. Thus, to avoid unnecessary treatment a person must clearly state what medical services are wanted at the end of life.
The issue is clouded by the huge shift in the doctor-patient-relationship over the past 10 years. The doctor who might see the patient in the primary care outpatient clinic is not the one who will see the patient at the care center, or the oncology clinic or be the admitting physician at the hospital. Unless the patient, family and friends have a clear grasp on what the patient wants the information may be lost or be misrepresented. It would be incorrect to think the medical record will be universally available — it’s not now and will probably not be that way for decades (if ever).
An equally difficult problem is the “grey area” between care that works and futile care. “Is this the end?” The care provider who is asked that question is really on the front line, not the primary care provider who discussed the issue 10 years before.
The elephant in the room is the cost of care. And, the fact many people do not have the resources to pay tens of thousands of dollars a month for care when their income is just Social Security. Very few people say “do everything”. But, can a person with no resources actually say “do everything” and expect that to happen?
The bottom line: the new CPT codes pay for something a primary care provider should already be doing so the additional cost is not needed. If the discussion is not happening then it is a case of poor quality primary care. Paying more never makes low quality care better, it just makes poor quality care more expensive.
An end-of-life discussion with a knowledgeable provider tends to set expectations in a reasonable range. Satisfaction with medical care is often about meeting expectations, so this is important for the patient and the care providers. It also should set expectations for friends and family — after the patient dies they are the ones who decide if expectations are met.