Medicare coverage of end-of-life counseling leaves some seniors skeptical
Gene Minich, 82, of Bethel Park, said he has a living will, but has not considered talking specifics of advanced age care with his doctor.
John, 80, of Bethel Park, said he won’t talk with doctors about advanced-age medical care, but will with his family. Despite his age, he said he has no living will nor a power of attorney on any document.
Medicare announced July 8 it would start reimbursing doctors in January for end-of-life and advanced care counseling as part of patients’ normal visits. But the news has left some senior patients skeptical, or resistant to have the conversation about prioritizing care, or even the basic steps of planning a living will. The initial push for late-age care counseling under Obamacare became politicized, and rhetoric of “death panels” became commonplace, but the taboo remains.
“It’s estimated about 25 percent of patients have not made living wills, afforded power of attorney or arranged similar advance care directives with their doctors or family,” said UPMC medical ethicist Jason Byron.
“An unfortunate but typical scenario is that the patient didn’t leave instructions, or family members give conflicting instructions and priorities, and then you have to have meetings with doctors, which is stressful for at least the family if not the patient,” Byron said.
One patient John, of Bethel Park, said he doesn’t buy the rationale of going over end-of-life care with a doctor.
“Just tell your family,” the 80-year-old said, explaining his wife has instructions for emergency situations. He said he has no living will.
“It seems like they’re getting money for nothing,” he said. “I’m paying in for Medicare to pay these doctors to talk about me dying.”
That skepticism is what doctors are, in turn, afraid of what patients are thinking.
“In studies where patients had these talks and resulting customized care, they reported they didn’t get depressed as much; the quality of care was better than those who didn’t have these talks; and, patients lived longer,” said Dr. Bob Arnold, chief medical officer at UPMC’s Palliative and Support Institute.
Short of saying the changes would incentivize these talks with doctors, Dr. Arnold said the change would be a welcome one.
“Doctors are so busy, especially in out patient or primary care settings, so for the federal government to say this attention to near-end-of-life care counseling is important, and it’s a great way to encourage both patients and doctors to actually take that time,” he said.
The questions typically asked in these counseling sessions, which answers are used for pain management and life support decisions, are couched in normal conversation, he said.
“What do you think about when you think about the future? What’s important to you? Given your medical condition and age, if you get better or worse, what should we do?” Dr. Arnold said were questions he’s asked patients.
Other seniors said they took steps years ago to alleviate the stress of decision making under circumstances involving pain or end of life.
“I’ve had a living will for 15 years,” said Gene Minich, 82, of Bethel Park. “But I’m not going to die, because I’m the bionic man. I’m on my second pace maker,” he said with a laugh.
Minich said he hasn’t had the same conversation with his doctors, but he’s open to it now that Medicare – and not only select private insurers – will start paying for the roughly 30-minute sessions.
A Turkish couple who’s been in the U.S. for 45 years and now reside in Upper St. Clair said they’re not worried about it because of their advanced age.
“We don’t want any life support,” said Semih, 88, on behalf of him and his wife, who is 83.
“Why try to extend our lives? Just let it end. We have lived our lives,” he said.
But Dr. Arnold said he hopes the attitude of patients like Semih don’t prevent them from informing their doctors.
“Doctors are like football coaches in the sense that you play the first quarter differently than the fourth quarter. It’s not ulterior motives, or the death panel stuff, it’s focusing on priorities that the patient wants addressed. They’re priorities we all need to address at some point.”