Posts Tagged end of life

Advance Care Planning — one more CPT code

cptbookThe 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.

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Advance Directives — end of life care

eskimoWhat is quality end-of-life care?  That can be a hard question because it depends on where a person lives, what the society expects, what the society can deliver and religious beliefs.  The Eskimo idea of putting grandma on an iceberg and sending her out with the tide is one view.   This primitive Eskimo practice is not without feeling or philosophy and focuses on the basics.  The family loves grandma, the family is in jeopardy trying to provide care and food,  and death should be painless and peaceful.

A modern society would add respect for a person’s wishes — such as religious views, desire for medical care, burial and distribution of assets.  But, despite the willingness of modern society to follow a person’s end-of-life requests a huge majority do not make end-of-life wishes known leaving family and doctors to just guess.  And, the result is expensive medical care and tremendous anxiety for the family — was that really a cultural advancement?

To try to make it easy for patients to make end-of-life medical care requests doctors have encouraged patients to provide them with “advance directives” — some statement in advance of death about what type and quantity of care is wanted at the end of life.  For many years the “living will” has been the vehicle for those requests.  As people fill out their will regarding property they often will fill out a “living will” with statements about what care they want or don’t want.

The “living will” has had problems because it was often filled out in a lawyer’s office without regard to the actual health of the patient or any understanding of advancing science or the grey area of incurable disease.

In the past 10 years a more rational approach has been growing in the form of “Medical Orders for Scope of Care”.  Which likewise is a legal document but one which is a true medical order issued by a licensed physician and discussed with the patient to match their wishes.  Click on the links to see examples:  IPOST, MOST and POLST.

Laura Landro of the Wall Street Journal wrote her story “Patients’ End-of-Life Wishes Granted, Study Finds” on 6/9/14  about an article in the Journal of the American Geriatrics Society:

Fromme, E. K., Zive, D., Schmidt, T. A., Cook, J. N. B. and Tolle, S. W. (2014), Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. Journal of the American Geriatrics Society. doi: 10.1111/jgs.12889

The essence of the article is that the health care system in Oregon does actually follow the POLST form requests.

There are several legal documents essential for someone approaching end-of-life:

  1. A will or trust.  Make bank accounts “payable on death” to some person.  Make sure securities are designated “transfer on death” to some person.
  2. A living will or MOST form (the latter is probably better)
  3. A power of attorney for health care form
  4. A power of attorney for property form
  5. A HIPPA form to designate who may have access to medical information.
  6. Identification documents: birth certificate, marriage certificate, social security card, state issued ID card (like a drivers license), health insurance card, and military discharge papers  — give copies to your power of attorney.
  7. Make sure the executor of your estate or trustee knows where to find a will,  trust documents,  bank information, life insurance policies, pension  information, funeral arrangements, deeds, and securities.


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