Obama's end-of life planning is all about "The Conversation"

President Obama’s “end-of-life plan” is all about The Conversation, but, for it to make sense, he has to shape the dialogue. What’s important is the language. What’s regrettable is that the NY Times headline today heralded “Obama Institutes End-of-Life Plan that Caused Stir.”
The opening of the article refers to the infamous “death panels” that caused a firestorm and nearly derailed the health reform law earlier this year. The notion of death panels is a huge distortion. The proposed reimbursement regulations are not talking about death panels, and the Obama Administration can’t let critics control the public debate, as it did before .

Health reimbursement practices have always paid doctors for procedures, but, especially in the case of primary care physicians, not enough for extended, thoughtful conversations. What the administration intends to do is pay them for the extra time they would spend on The Conversation that each and every one of us would do well to have with our doctors as well as our families.

The Conversation should be part of our wellness care, a routine part of health planning. The Conversation may indicate that, if we are terminal and on life support, we don’t want our lives artificially prolonged by modern technology. Or maybe, for a variety of reasons, we do want to be sustained indefinitely on a breathing machine, hovering between life and death. Having The Conversation is all about making our wishes known while we are mentally and physically able to make those decisions for ourselves. We need information from our doctors if we are to make informed choices and help shape our own medical outcomes.

Maybe we want to write a living will. Maybe we want to know what’s involved in organ donation. Maybe we want to learn more about designating a health proxy. Maybe we’ve already executed such documents but haven’t talked about them with our loved ones or with our doctors. Health experts indicate that more people have spoken with their loved ones about this than with their doctors.

But doctors need to hear our wishes as well. After all, for most doctors, the mission is to save lives, to try absolutely everything, even if the likelihood of a positive outcome is slim to none. The more experienced and thoughtful ones know that part of their mission needs to be explaining to patients what things will look like if life is artificially sustained, and what a “good death” can be with the options of hospice, pain medication, and other palliative care. This isn’t about the government deciding who shall live and who shall die, but our taking charge of our care, deciding, as patients, what we want for ourselves under different circumstances.

Studies show that, while 70 percent of patients say they want to die at home, fully 70 percent in fact die in the hospital, often in the Intensive Care Unit. For survivors, that can translate into guilt and depression. How much better to be able to say, in our grief over a loved one’s passing, that that loved one had the death he or she wanted. Those who have studied this area tell us that sometimes patients who choose palliative rather than aggressive care enjoy a better quality of life at the very end.

Aetna Insurance has experimented with a “compassionate care” program, letting patients with life expectancy of a year have hospice care without having to give up other, curative care. In the program, the percentage of patients choosing hospice care nearly tripled. People want to be able to choose how they’re cared for once they know what the different possible outcomes are. That’s what The Conversation with doctors is all about, and why it should be part of the ongoing care that doctors provide, an important regular conversation that health care reimbursement plans take into account. The Obama administration should keep focused on that and not lose control of the public dialogue. And media headline writers should resist the temptation to exploit the political extremes that grab attention but undermine the public good.

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