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As an intern admitting emergency-room patients to a Cincinnati hospital, I saw it happen again and again: Late-stage cancer patients in the midst of medical crises would roll into our ER in need of a ventilator as expected complications mounted.
We would ask for their advance directives, who had their power of attorney, and whether they had considered “do not resuscitate” orders or hospice. Too often, these concepts were unfamiliar, even for patients who had been undergoing cancer treatments for months or years.
If it ever makes its way out of Congress, a bipartisan bill introduced last month in the Senate Finance Committee would correct some of the structural problems that lead to this sad and costly phenomenon. For too long, American medicine has pushed off the big conversations with the sickest patients until too late.
Coming to terms with such weighty decisions in an ER bay or with loved ones hovering around a bed in the intensive-care unit is too late, especially when a deadly diagnosis is known well before the hospitalization.
Once the patient is “sedated and intubated” and the family is in shock, the most valuable window into the patient’s true desires has been lost. When patients haven’t had the chance to wrestle with their values in the context of all their options and haven’t talked out their preferences before their critical-care scenario begins, their families will make aggressive choices on their behalf.
Democratic Sen. Mark Warner of Virginia, the driving force behind the Care Planning Act, experienced these same pressures during his mother’s declining years. Warner’s bill, co-sponsored with Georgia Republican Sen. Johnny Isakson, identifies the need for a detailed, structured discussion between the patient and their health care providers, family, friends and other support such as faith leaders - a discussion Warner’s family never had with his mother.
The reason, as is so often the case in health care, is what gets paid for. Such meetings, while of enormous value to the health care system as a whole, have never had a corollary in professional billing, meaning it often doesn’t occur.
The result is bewildering tales like those from the Cincinnati ER, where many of my patients on life support never had the option to choose hospice instead of the ICU. In fact, a 2010 study of 325 terminally ill cancer patients found that only 39 percent had discussed their end-of-life care choices with their oncologists.
The Care Planning Act would create a billing code for “planning services,” allowing physicians to charge for these lengthy and challenging sessions with patients and their extended support networks. The legislation goes on to require that the meeting result in a documented plan.