In a recent blog post I pointed out some legislative initiatives that essentially make certain principles of geriatric practice required by law. I noted how these laws can be interpreted as an effort to make up for the scarcity of practicing geriatricians, and the lack of geriatrics training for most physicians in America. President Obama has continued this trend by signing a new Medicare regulation which provides reimbursement to physicians who advise patients on options for end-of-life care, effective January 1st. End-of-life decision making may include advance directives such as living wills and health care proxies, palliative care or hospice programs, and choices about life sustaining technologies such as ventilators, feeding tubes, defibrillation, and others.
In America, our healthcare system is sometimes in denial about the processes of aging and death. An unfortunate byproduct is lack of education regarding reasonable options for end-of-life decision making. The result is application of aggressive and advanced technology to prolong life, often in the setting of a hopeless prognosis. This can result in needless suffering and monetary expense, and death without dignity or consideration of the patient’s preferences. A basic principal of geriatrics is to discuss advance directives and counsel patients on reasonable end-of-life choices, with the goal of dignity, autonomy, and curtailment of unnecessary suffering.
Geriatrics is a subject that does not have substantial emphasis during the medical undergraduate curriculum, despite the fact that the over 85 age group is the most rapidly growing sector of American society. In the face of a growing elderly population there are diminishing numbers of graduating physicians entering the field of geriatrics. The processes of aging are often not recognized in clinical practice, and end-of-life choices are frequently not addressed by physicians. The results can translate into needless surgical procedures, ICU and hospital stays, and inter-institutional transfers that increase the chances of medically induced illness.
Section 1233 was the component of the Health Care Reform legislation that allowed reimbursement for end-of-life counseling. This issue became politically charged with some conservatives mischaracterizing the legislation as “death panels,” and claiming that it encouraged euthanasia. As a result Section 1233 was dropped from the Health Care Reform bill. Provisions of this deleted clause were essentially resurrected and incorporated into a service covered under the Medicare wellness benefit, allowing doctors to discuss end-of-life options as part of the regular yearly visit. This was signed by President Obama and goes into effect January 1, 2011.
With the medical establishment often removed from implementing principles of geriatric care, the government has turned to legislation to make up the practice gap. The results include financial incentives to promote reasonable care, financial penalties for poor care (see my post on pressure ulcers in hospitals), and complex laws that govern medical assessments of nursing home patients. Given the limited progress that geriatrics has made in penetrating the mainstream of healthcare, legislative incentives to enforce reasonable practices for care of the elderly will continue as our population ages. The challenge remains to educate physicians about the nature of advance directives and reasonable choices for care at the end of life. Physicians may also need training on how to provide this counseling – something which is often uncomfortable for families and patients as well as caregivers.
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Read the New York Times article on this topic.